Response to Kavalieratos: Directing the Narrative to Define and Present Standardization in Palliative Care (DOI: 10.1089/jpm.2019.0548)

Dear Editor:

For the past few months, we have often come back to the associate editor, Dio Kavalieratos' letter, “Directing the Narrative to Define and Present Standardization in Palliative Care.” ¹ The letter so poignantly illustrated the difficulties of understanding and proving palliative care's impact when uniformity and standardization in palliative care delivery is the exception, not the rule. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care provide a foundation for uniformity. However, given the wide variation in program development and access to resources, it is erroneous to assume that all palliative care programs have consistently implemented the guidelines.^2,3

There is a saying, “if you've seen one palliative care program, you've seen one palliative care program.” This theme ripples through the published literature on palliative care interventions. We, too, are guilty of excitedly disseminating a new study that shows successful outcomes resulting from “palliative care” without fully understanding the intervention or the model. We have been surprised by how many published peer-reviewed studies do not include basic information about the structures and processes of care that define the palliative care program. Did the team have a social worker? What were the caseloads? Was it only available Monday–Thursday? Did anyone have specialty palliative care certification?

As a reader, these omissions create difficulty in understanding how study results translate to general practice or apply to our programs. This information gap also reduces the utility of palliative care publications with null results, where the lack of impact could be due to the definition of the program. More importantly, this lack of clarity puts into question the integrity of systematic reviews and meta-analyses, in which the results of heterogeneous palliative care models are combined and presented together. ⁴ As Dr. Kavalieratos stated in his letter, we cannot expect “uniform benefits” from diverse models.

Beyond the translation of research to practice, the omission of basic structural data in published research threatens our long-term credibility to external stakeholders. Published literature is utilized by policymakers and the media, who may be inclined to accept the high-level conclusions about palliative care without further probing. It is not a stretch to see how this could negatively impact future perceptions and support of palliative care.

Of our field's many challenges, this is fixable. Academic journals, including the Journal of Palliative Medicine, should hold their submitting authors to a higher standard and require all articles to describe their palliative care program's structure and delivery model (Table 1). The inclusion of these minimum requirements would improve utility and dissemination and not add excessive burden. Consistently available structure and process information would push the field forward in understanding the nuances across palliative care delivery models, lead to better understanding of study results, and not only aid in moving toward standardization but also help to identify models with unique characteristics that work best for specific populations.

Only when authors include details of their model, can we begin to dissect the impact of palliative care. We challenge the journal to lead this charge.