ETHICS, PUBLIC POLICY, AND MEDICAL ECONOMICS A Systematic Review of Satisfaction with Care at the End of Life Sydney Morss Dy, MD, MSc, à wz Lisa R. Shugarman, PhD, § Karl A. Lorenz, MD, MSHS, §k Richard A. Mularski, MD, MSHS, # and Joanne Lynn, MD, MA, MS, § for the RANDFSouthern California Evidence-Based Practice Center (See editorial comments by Dr. Jean S. Kutner, pp 160–162) The objective of this study was to systematically review the literature to better understand the conceptualization of sat- isfaction with end-of-life care and the effectiveness of pal- liative care interventions on this outcome. Data sources included Medline and the Database of Reviews of Effects. The review included relevant qualitative studies and inter- vention studies using satisfaction as an outcome from 1990 to 2005. Reviewing 24,423 citations yielded 21 relevant qualitative studies, four systematic reviews, and eight ad- ditional intervention studies. The qualitative literature de- scribed the domains of accessibility and coordination; competence, including symptom management; communi- cation and education; emotional support and personaliza- tion of care; and support of patients’ decision-making. For collaboration and consultation interventions, eight of 13 studies showed a significant effect on satisfaction. A meta- analysis found that palliative care and hospice teams im- proved satisfaction, although most studies did not include satisfaction as an outcome. For other types of interventions, only two of six showed a significant effect. For heart failure coordination of care, only seven of 32 studies addressed this as an outcome; two of the three that compared satisfaction between groups showed a significant difference. Evalua- tions used many different measures, only one of which was designed for the end of life. In conclusion, researchers have conceptualized satisfaction in palliative care, and different types of palliative care interventions can improve satisfac- tion, but it is often not included as an outcome. More focus on these satisfaction elements might improve the effective- ness of end-of-life interventions and their evaluation. J Am Geriatr Soc 56:124–129, 2008. Key words: systematic review; satisfaction; end-of-life care; palliative care W hen patients living with advanced illness near the end of life, the purpose of health care shifts to meeting the subjective needs of patients and families. Important patient- centered outcomes of care include symptoms, spiritual well- being, longevity, functional status, caregiving burden, and symptoms of bereavement. 1 Researchers often lack guid- ance in choosing which domains to measure in assessing end-of-life interventions and determining how health care can affect these domains. Satisfaction with care is a metric that might integrate different aspects of patients’ and care- givers’ experiences of end-of-life care, but to be effective, measurement of satisfaction must address aspects that are important to patients and be responsive to improvements in healthcare delivery. As part of a systematic review of end-of-life care, sat- isfaction was evaluated as an outcome of healthcare inter- ventions. The qualitative literature was reviewed to evaluate the domains of satisfaction with end-of-life care, inter- actions with other concepts (such as quality of life), and how evaluating satisfaction differs between key conditions, respondents, and settings. The literature on palliative care interventions was reviewed to determine the effectiveness of collaboration and consultation, other palliative care interventions, and coordination of care for heart failure on satisfaction as an outcome. METHODS The methods for the comprehensive search and overall search results are discussed in detail elsewhere. 1 Sources included Medline, the Database of Reviews of Effects, the National Consensus Project for Palliative Care, the Na- tional Institute for Clinical Excellence, and Health Canada. The main search strategy included an extensive list of terms intended to identify all research publications addressing palliative and end-of-life care and the full scope of relevant healthcare settings. The searches were limited to published English-language articles in the Western literature from 1990 to 2004 involving human subjects; the review of interventions was updated through November 2005. Ex- clusions included studies addressing only technical interventions (such as surgery) or only physiological, laboratory, or radiological outcomes; studies without Address correspondence to Sydney M. Dy, MD, MSc, Room 609, 624 North Broadway, Baltimore, MD 21205. E-mail: sdy@jhsph.edu DOI: 10.1111/j.1532-5415.2007.01507.x From the Departments of à Health Policy and Management; w Oncology, and z Medicine, Johns Hopkins University, Baltimore, Maryland; § Southern California Evidence-Based Practice Center and RAND Health, Santa Monica, California; k Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; # Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. JAGS 56:124–129, 2008 r 2007, Copyright the Authors Journal compilation r 2008, The American Geriatrics Society 0002-8614/08/$15.00