Out-of-hours specialist and generalist palliative care service provision. An evidence review

Inadequate community supports and deficiencies in access to services outside of regular office hours have been linked to poor outcomes for patients with life-limiting illness. Policy-makers, researchers, providers, patients, and carers in Ireland have all identified out-of-hours care as a key deficit in current service provision. The Department of Health commissioned this review to inform the revision of national palliative care policy and address the recognised challenges in providing out-of-hours palliative care. Therefore, the purpose of this evidence review was to synthesise evidence regarding the provision of out-of-hours palliative care for adults.

This systematic review of both peer-reviewed and grey literature identified no studies of sufficient quality that evaluated the effect of out-of-hours palliative care on patient and caregiver outcomes nor on cost and cost-effectiveness. The grey literature review included policy and practice documentation for 16 high-income countries, selected due to their well-integrated palliative care services. We identified widespread consensus about the importance of integrated, 24-hour palliative care in principle; however, descriptions of out-of-hours care were very limited. Specific examples of innovative care models were described in some documents. Only one set of performance measures specifically for out-of-hours palliative care was identified, but these indicators had not been assessed for validity or usefulness.

We identified more barriers than facilitators regarding challenges to implementation. Barriers included insufficient resources, inadequate knowledge among practitioners and patients, a lack of guidance for non-specialists, inadequate communication between out-of-hours services and other parts of the healthcare system, and insufficient knowledge or confidence among unpaid caregivers.

The findings of this review indicate that Ireland’s current position is typical among high-income countries with well-established services. That is, the importance of integrated, 24-hour care for people with serious and complex medical illness is widely acknowledged, but details on how to organise, provide, and evaluate out-of-hours services are scant. The need for ongoing evaluation of the feasibility and effectiveness of new and existing services is critical in the context of very limited international evidence.