***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: To provide a detailed description of the recommendations of a Palliative Care Service ( PCS ) and to describe the impact of these recommendations on the care of terminally ill patients in an academic medical center , we describe data from all consecutive patients referred by their attending physicians to the PCS of an academic teaching hospital over a 15-month period . All patients were seen within 24 hours of consultation request . Data were collected prospect ively on the day of discharge or death . Attention was focused on six recommendations and their implementation : 1 ) discussion about prognosis and goals of care ; 2 ) pursuing documentation of advance directives ; 3 ) discussion about foregoing specific treatments and /or diagnostic interventions ; 4 ) family and patient support ; 5 ) discharge planning ; and 6 ) symptom management .  Over a 15-month period , we collected data on 325 patients . The most frequent diagnoses were cancer , dementia , and HIV disease . The patients were followed for a mean of 7.6 days . The average number of recommendations was 4.2 per patient and 91 % of the recommendations were implemented ( 3.8 per patient ) . Recommendations increased to 5.3 per patient and the implementation rate increased to 97 % ( 5.1 per patient ) for the 44 patients transferred to the Palliative Care Unit ( PCU ) . PCS consultations result in multiple recommendations with a very high implementation rate . The number of recommendations and the high implementation rate suggest a strong need for palliative care services within acute care hospitals Australian palliative care is delivered by general practitioners ( GPs ) and specialist palliative care teams . Patient outcomes should improve if they work in formal partnership . We conducted a multi-centred r and omised controlled trial of  specialist- GP case conferences , with the GP participating by teleconference , or usual care and communication methods . Primary outcome measure was global Quality of Life ( QoL ) scores at 3 weeks from intervention . Secondary measures included subscale QoL scores and carer burden . Two a priori intention-to-treat analyses were conducted using recruitment , and time of death , as fixed time points . There was no difference between groups in the magnitude of change in global QoL measures from baseline to any time point up to 9 weeks post-case conference , or at any time before death . The case conference group showed better maintenance of some physical and mental health measures of QoL in the 35 days before death . Case conferences may improve clinical relationships and care plans at referral , which are not implemented until severe symptoms develop . Case conferences between GPs and specialist palliative care services may be warranted for palliative care patients PURPOSE The purpose of this study was to describe and show effectiveness of the outreach team model of palliative care ( PC ) in allowing home death for children with incurable cancer . PATIENTS AND METHODS Over 7 months , 185 children from 22 United Kingdom oncology centers were recruited to a prospect i ve question naire survey . RESULTS One hundred sixty-four children from 22 centers died ( median age , 8.7 years ; 88 boys , 76 girls ) . One hundred twenty-six families completed two or more question naires . One hundred twenty ( 77 % ) of 155 with complete data died at home . Preference for home death was recorded in 90 ( 68 % ) of 164 and 132 ( 80 % ) 164 at study entry and last month of life , respectively . Death occurred in preferred place for 84 ( 80 % ) of 105 with recorded preference at entry . Forty-one ( 25 % ) of 164 and 68 ( 41.5 % ) of 164 needed no outpatient or inpatient hospital visits , respectively . A named individual provided on-call  PC advice by phone or home visit in 22 ( 100 % ) and 18 ( 82 % ) of 22 oncology centers , respectively . As PC progressed , involvement of oncologist and social worker appeared less , whereas pediatric oncology outreach nurse specialists ( POONSs ) remained prominent . CONCLUSION Preference for home death expressed by families in our study is similar to others , but the proportion of children actually able to die there is higher . Home death is facilitated by this model . Key components are POONSs , pediatric palliative and /or oncology specialist , and general practitioner . Professional roles change during PC and after death . An ongoing role for the oncology team in bereavement support is highlighted OBJECTIVE To document outcomes of a r and omized trial of the PhoenixCare demonstration program of palliative care and coordinated care/case management for seriously chronically ill individuals who simultaneously received active treatment from managed care organizations ( MCOs ) . DESIGN Patients , continuously enrolled between July 1999 , and March 2001 , were r and omly assigned to the PhoenixCare program  or a control group receiving usual MCO care . SETTING Hospice of the Valley , Phoenix , Arizona . PARTICIPANTS Participants were 192 patients with chronic obstructive pulmonary disease ( COPD ) or chronic heart failure ( CHF ) , who had an estimated 2-year life expectancy . INTERVENTION Intensive home-based case management provided by registered nurse casemanagers , in coordination with patients ' existing source of medical care , comprised the intervention . Program foci included disease and symptom management , patient self-management of illness and knowledge of illness-related re sources , preparation for end-of life , physical and mental functioning , and utilization of medical services . OUTCOME MEASURES Outcomes , assessed every 3 months by telephone interview , included measures related to all program foci ; the SF-36 was used to evaluate physical and mental functioning ; emergency department visits exemplified medical service utilization . RESULTS Compared to controls , PhoenixCare patients exhibited significantly better outcomes on self-management of illness , awareness of illness-related re sources , and legal preparation for end of life . They reported lower symptom distress , greater vitality , better physical functioning and higher self-rated health than r and omized controls . Emergency department utilization was equivalent across groups . Patients with COPD showed stronger responsiveness to the intervention . CONCLUSION A novel model of patient care that combined greatly enhanced palliative carefocused case management with ongoing MCO-based treatment was associated with improved functioning of chronically severely ill patients in the last years of life BACKGROUND Little is known about the use of palliative care for out patients who continue to pursue treatment of their underlying disease or whether outpatient palliative medicine consultation teams improve clinical outcomes . METHODS We conducted a year-long controlled trial involving 50 intervention patients and 40 control patients in a general medicine outpatient clinic . Primary care physicians referred patients with advanced congestive heart failure , chronic obstructive pulmonary disease , or cancer who had a prognosis ranging from 1 to 5 years . In the intervention group , the primary care physicians received multiple palliative care team consultations , and patients received advance care planning , psychosocial support , and family caregiver training .  Clinical and health care utilization outcomes were assessed at 6 and 12 months . RESULTS Groups were similar at baseline . Similar numbers of patients died during the study year ( P = .63 ) . After the intervention , intervention group patients had less dyspnea ( P = .01 ) and anxiety ( P = .05 ) and improved sleep quality ( P = .05 ) and spiritual well-being ( P = .007 ) , but no change in pain ( P = .41 ) , depression ( P = .28 ) , quality of life ( P = .43 ) , or satisfaction with care ( P = .26 ) . Few patients received recommended analgesic or antidepressant medications . Intervention patients had decreased primary care ( P = .03 ) and urgent care visits ( P = .04 ) without an increase in emergency department visits , specialty clinic visits , hospitalizations , or number of days in the hospital . There were no differences in charges ( P = .80 ) . CONCLUSIONS Consultation by a palliative medicine team led to improved patient outcomes in dyspnea , anxiety , and spiritual well-being , but failed to improve pain or depression .  Palliative care for seriously ill out patients can be effective , but barriers to implementation must be explored Background In contemporary medical research , r and omised controlled trials are seen as the gold st and ard for establishing treatment effects where it is ethical and practical to conduct them . In palliative care such trials are often impractical , unethical , or extremely difficult , with multiple method ological problems . We review the utility of Cochrane review s in informing palliative care practice . Methods Published review s in palliative care registered with the Cochrane Pain , Palliative and Supportive Care Group as of December 2007 were obtained from the Cochrane Data base of Systematic Review s , issue 1 , 2008 . We review ed the quality and quantity of primary studies available for each review , assessed the quality of the review process , and judged the strength of the evidence presented . There was no prior intention to perform any statistical analyses . Results 25 published systematic review s were identified . Numbers of included trials ranged from none to 54 . Within each review , included trials were heterogeneous with respect to patients , interventions , and outcomes , and the number of patients contributing to any single analysis was generally much lower than the total included in the review . A variety of tools were used to assess trial quality ; seven review s did not use this information to exclude low quality studies , weight analyses , or perform sensitivity analysis for effect of low quality . Authors indicated that there were frequently major problems with the primary studies , individually or in aggregate . Our judgment was that the review ing process was generally good in these review s , and that conclusions were limited by the number , size , quality and validity of the primary studies .We judged the evidence about 23 of the 25 interventions to be weak . Two review s had stronger evidence , but with limitations due to method ological heterogeneity or definition of outcomes . No review provided strong evidence of no effect . Conclusion Cochrane review s in palliative care are well performed , but fail to provide good evidence for clinical practice because the primary studies are few in number , small , clinical ly heterogeneous , and of poor quality and external validity . They are useful in highlighting the weakness of the evidence base and problems in performing trials in palliative care OBJECTIVES To determine whether palliative care teams can improve patient , family and staff satisfaction for patients receiving end-of-life care in the intensive care unit and reduce surrogate markers of health care costs . DESIGN R and omised controlled , feasibility study . SETTING 14-bed general ICU over 29 months in 2006 - 2008 . PARTICIPANTS Patients admitted with a terminal or preterminal condition , for whom the treating intensivist considered that escalating or continuing treatment was unlikely to achieve significant improvement in the patient 's clinical condition . INTERVENTION A consultation from a palliative care team , in addition to usual ICU end-of-life care . MAIN OUTCOME MEASURES ICU and hospital length of stay , and changes in composite scores of satisfaction obtained from question naires administered to families , nursing staff and intensivists . RESULTS The study was constrained by significant logistical and method ological problems , including low recruitment and question naire completion rates , and the lack of an available vali date d question naire . From a total of 2009 admissions over a 29-month period , 20 patients were enrolled , 10 in each group . There were significant differences in baseline characteristics . There were no statistically significant differences between those who had a consultation with the palliative care team and those who did not in median ICU length of stay ( 3 days v 5 days , P=0.97 ) , median hospital length of stay ( 5 days v 11 days , P=0.44 ) , or changes in overall composite satisfaction scores reported by families ( -6 % v -6 % , P=0.91 ) , nursing staff ( + 5 % v + 15 % , P=0.30 ) , and intensivists ( -2 % v + 2 % , P=0.42 ) . CONCLUSION This feasibility study was difficult to conduct and did not generate any robust conclusions about the utility of involving palliative care teams in end-of-life care in the ICU . Larger studies are technically possible but unlikely to be feasible . TRIAL REGISTRATION Australian Clinical Trials Registry ACTRN012606000110583 OBJECTIVE There is a paucity of r and omized controlled trials ( RCTs ) to evaluate models of palliative care . Although interventions vary , all have faced a variety of method ological challenges including adequate recruitment , missing data , and contamination of the control group . We describe the ENABLE II intervention , methods , and sample baseline characteristics to increase intervention and method ological transparency , and to describe our solutions to selected method ological issues . METHODS Half of the participants recruited from our rural U.S. comprehensive cancer center and affiliated clinics were r and omly assigned to a phone-based , nurse-led educational , care coordination palliative care intervention model . Intervention services were provided to half of the participants weekly for the first month and then monthly until death , including bereavement follow-up call to the caregiver . The other half of the participants were assigned to care as usual .  Symptoms , quality of life , mood , and functional status were assessed every 3 months until death . RESULTS Baseline data of 279 participants were similar to normative sample s. Solutions to method ological challenges of recruitment , missing data , and " usual care " control group contamination are described . SIGNIFICANCE OF RESULTS It is feasible to overcome many of the method ological challenges to conducting a rigorous palliative care RCT CONTEXT There are few r and omized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer . OBJECTIVE To determine the effect of a nursing-led intervention on quality of life , symptom intensity , mood , and re source use in patients with advanced cancer . DESIGN , SETTING , AND PARTICIPANTS R and omized controlled trial conducted from November 20 
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Variation in the content of models , context s in which these were implemented and lack of detailed reporting meant that elements of models constituted a more meaningful unit of analysis than models themselves .
Case management was the element most consistently reported in models for which comparative studies provided evidence for effectiveness .
Essential attributes of population -based palliative care models identified by policy and addressed by more than one element were communication and coordination between providers ( including primary care ) , skill enhancement , and capacity to respond rapidly to individuals ’ changing needs and preferences over time .
Conclusion Models of palliative care should integrate specialist expertise with primary and community care services and enable transitions across setting s , including residential aged care .