Background
Increased life expectancy is an outcome of scientific and technological advances.1 Therefore, population aging in societies where death can be delayed is an indicator of a steady increase in the prevalence of degenerative and disabling diseases, and consequently of sources of suffering.2,3 This represents a challenge for healthcare services and requires a holistic approach based on the biomedical model and focused on somatic symptoms that go beyond the psychological, social and spiritual domains.4 This holistic paradigm calls for new measures to reduce suffering and provide comfort which are the key goals of medicine, particularly in palliative care (PC).
Callahan5 proposed two main goals for 21st-century medicine: first, to prevent and cure diseases, and to help human beings die in peace. Since death is inevitable, enabling people to die peacefully is as important as preventing and curing diseases, hence the advent of PC as a response to the suffering associated with the dying process.6 According to the World Health Organization, PC is "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual".7(p.84)
Confrontation with death, gradual deterioration in health, debilitating physical symptoms, and emotional and spiritual distress experienced by people with incurable and advanced disease (IAD) make the process of living with the disease longer than necessary, more painful, and one of intense suffering.8,9 In addition, treatments sometimes increase patients' levels of anxiety, depression and physical discomfort, with a significant negative impact on their comfort and well-being.10,11 Incurable and advanced diseases are incurable conditions associated with a limited response to specific treatments, a high emotional impact, and a decreased life expectancy. In this situation, therapeutic strategies focus on optimizing comfort.12,13
Pharmacological techniques have improved and are now more capable of managing physical pain. However, PC extends beyond the relief of physical symptoms as it seeks to strengthen the psychological, spiritual and social domains in order to provide greater comfort to people with IAD.1,14 Kolcaba defined comfort as "the satisfaction (actively, passively or co-operatively) of the basic human needs for relief, ease or transcendence arising from health care situations that are stressful" in the physical, social, psychospiritual, and environmental contexts.15(p.1178) Therefore, pain, suffering, fatigue, depression and anxiety were analyzed in this review as factors that influence the level of comfort.16,17
The increasing need for PCUs1,18 requires better end-of-life care to minimize suffering and provide comfort. According to Cicely Saunders,19 given their closer contact with patients, nurses are in a unique position to promote comfort.8 Indeed, over time, the promotion of comfort has become a central focus and concern of nursing.20
Research shows that comfort is a key element of care;21 however, its meaning is often implicit, and usually leads to ambiguity.22 Based on Kolcaba's23 theory of comfort, it is a desirable holistic purpose of the nursing discipline. Thus, nurses must assess the healthcare needs verbally and nonverbally reported by patients in stressful situations, namely, IADs.15
Nurses should implement comfort measures to meet these needs, as well as reassess comfort levels after their implementation. According to Kolcaba, "assessment (intuitive or formalistic) precedes intervention".23(p.107) Assessment may be intuitive, for example, when a nurse asks if the patient is comfortable, or formalistic, such as in the observation of wound healing, and the administration of visual analogue scales or traditional questionnaires.23,24
Comfort interventions make patients feel strengthened in a personalized and an intangible way. Comfort allows patients to experience a more peaceful death,25,26 which Kolcaba defines as "one in which conflicts are resolved, symptoms are well managed, and acceptance by the patient and family members allows for the patient to 'let got' quietly and with dignity".23(p.80)
Therefore, non-pharmacological interventions have been increasingly used in PCUs to promote comfort27,28 and improve patient satisfaction with end-of-life care.29 Some studies on the implementation and evaluation of non-pharmacological interventions to promote comfort or other comfort-related outcomes, such as well-being, pain, suffering, stress, fatigue, anxiety and depression, particularly in patients with IAD,30-33 have shown that hypnotherapy30 (measured through the Anxiety and Depression Scale) reduces anxiety in hospice patients, and that art therapy31 (measured through the Edmonton Symptom Assessment Scale) reduces pain, fatigue, depression and anxiety in patients admitted to PCUs.
Other studies have also analyzed the impact of non-pharmacological interventions on cancer patients with IAD and concluded that interventions based on aromatherapy, relaxation and mental images provide feelings of relaxation, serenity, and comfort.32,33 However, data on the characteristics, contexts and populations of these interventions are scattered in the literature,27,34,35 hindering the development of a systematic review on their effectiveness.
Moreover, non-pharmacological interventions implemented in PC are yet to be summarized, and research tends to focus on the somatic aspects of comfort35-37 instead of addressing the multiple comfort-related dimensions. Furthermore, these studies do not describe the characteristics of the different non-pharmacological interventions, so the implementation and evaluation of non-pharmacological interventions in non-cancer patients remain unclear.
Therefore, the purpose of this review was to analyze the above-mentioned aspects so that a systematic review can be conducted on the effectiveness of interventions for improving comfort in specific contexts and/or populations, or on the effectiveness of certain characteristics of the interventions aimed to promote comfort. As a result, this scoping review aimed to address important questions about the existing evidence on this area before a specific question can be formulated on the effectiveness of these interventions.
Since non-pharmacological interventions can improve the comfort of patients with IAD, it is imperative to map the evidence on this issue as an initial step for the development of a systematic review.36,37
This scoping review was guided by the methodology proposed by the Joanna Briggs Institute for scoping reviews,38,39 and aimed to examine and map non-pharmacological interventions implemented and evaluated to provide comfort to people with IAD, their characteristics and contexts, as well as the type of advanced disease. According to the Joanna Briggs Institute, "scoping reviews undertaken with the objective of providing a map of the range of the available evidence can be undertaken as a preliminary exercise prior to the conduct of a systematic review".38(p.6) Therefore, this mapping allows the identification of relevant issues to help advance evidence-based healthcare, increase knowledge, identify gaps and inform systematic reviews.
This scoping review is part of a research project involving the conduct of a systematic review on the effects of non-pharmacological interventions aimed at providing comfort to people with IAD. In addition, this mapping will inform the development of appropriate and effective interventions to improve the comfort of people with IAD.
An initial search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, MEDLINE and CINAHL revealed that there was no scoping review (published or in progress) on this topic.
The objectives, inclusion criteria and methods of analysis for this review were previously established and documented in a protocol.40
Review question/objectives
The objective of this scoping review was to examine and map the non-pharmacological interventions implemented and evaluated to provide comfort in PC.
More specifically, the review focused on the following questions:
1. What non-pharmacological interventions have been implemented and evaluated to provide comfort to patients with IAD?
2. What are the characteristics (duration, dose and frequency) of these interventions?
3. In what contexts (home care, PCU or hospice) have the non-pharmacological interventions been implemented and evaluated?
4. In which populations (cancer and non-cancer patients) have the non-pharmacological interventions been implemented and evaluated?
Inclusion criteria
Types of participants
This scoping review considered all studies that focused on patients with IAD, aged 18 years or over, assisted by PC teams.
The term IAD is understood to be an incurable condition associated with limited response to specific treatments, high emotional impact and decreased life expectancy. In these situations, therapeutic strategies focus on optimizing comfort (comfort treatment).12,13
Therefore surviving cancer or cancer patients receiving curative treatment were excluded.
Concepts
This scoping review considered all studies that addressed non-pharmacological interventions implemented and evaluated to provide comfort.
It considered non-pharmacological interventions implemented not only to provide comfort but also well-being and relief of pain, suffering, anxiety, depression, stress and fatigue, which are comfort-related concepts.
Context
This scoping review considered all non-pharmacological interventions implemented and evaluated in the context of PC. This included home care, hospices or PCUs.
Types of sources
This scoping review considered quantitative and qualitative studies, and systematic reviews.
Quantitative designs included any experimental study designs (including randomized controlled trials, non-randomized controlled trials, or other quasi-experimental studies, including before and after studies), and observational designs (descriptive studies, cohort studies, cross-sectional studies, case studies, and case series studies).
Qualitative designs included any studies that focused on qualitative data such as, but not limited to, phenomenology, grounded theory and ethnography designs.
Systematic reviews included meta-analyses and meta-syntheses.
Search strategy
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was used in this review. An initial limited search of MEDLINE (via PubMed) and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. Studies published in English, Spanish and Portuguese were considered for inclusion in this review, regardless of their year of publication to capture how non-pharmacological interventions implemented and evaluated to provide comfort in PC have been researched and understood over time.
The search was conducted in the following sources:
CINAHL Plus with Full Text
PubMed
Cochrane Central Register of Controlled Trials
LILACS
Scopus
Library, Information Science and Technology Abstracts
SciELO - Scientific Electronic Library Online
PsycINFO
JBI Database of Systematic Reviews and Implementation Reports
Cochrane Database of Systematic Reviews
The search for unpublished studies included:
ProQuest - Nursing and Allied Health Source Dissertations
Banco de teses da CAPES (Brazil)
Teseo - Base de datos de Tesis Doctorales (Spain)
TDX - Tesis Doctorals en Xarxa (Spain)
RCAAP - Repositorio Cientifico de Acesso Aberto de Portugal
The following initial keywords in English were used: comfort OR pain OR suffering OR anxiety OR depression OR stress OR fatigue OR well-being palliative; hospice; "home care"; "end of life"; intervention
The full search strategy is presented in Appendix I.
Articles searched were then assessed for relevance to the review, based on the information provided in the title and abstract, by two independent reviewers. The full article was retrieved for all studies that met the inclusion criteria of the review. If the reviewers had doubts about the relevance of a study from the abstract, the full-text article was retrieved.
Two reviewers examined the full-text articles independently to check whether they met the inclusion criteria. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer.
Studies identified from reference lists were assessed for relevance based on their title and abstract.
Extraction of results
Data were extracted from articles included in the review using a charting instrument aligned with this research objective and question (Appendix II), as indicated by the methodology for scoping reviews developed by the Joanna Briggs Institute.38
Two reviewers extracted data independently. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer.
Both reviewers independently charted the "first five to ten studies using the data-charting form and meet to determine whether their approach to data extraction is consistent with the research question and purpose", as suggested by Levac et al.41(p.6) In addition, when necessary, primary authors were contacted for further information/clarification of data, as suggested by Arksey and O'Malley.42
Results
After the duplicates were removed, 868 records were identified for study selection. A total of 90 documents met the inclusion criteria, based on the titles and abstracts. The full-text articles were then obtained. Full-text articles were read, and 18 articles met the inclusion criteria (the reasons for exclusion of full-text articles are presented in Appendix III). Figure 1 shows the study selection process. Details on the studies are presented in Appendix IV.
Country of publication
Most of the studies included in this scoping review were conducted in the USA43-45 and Japan,46-48 as shown in Table 1.
Research design
Eleven studies used a quantitative design,30,43,45,47-54 one a qualitative design,55 and three a mixed-methods design.28,31,56Table 2 shows the studies included in this scoping review by study design.
Year of publication
Included studies were published between 1998 and 2015. Table 3 shows the year of publication of studies included in this scoping review.
Non-pharmacological interventions
The 18 included studies implemented and evaluated 10 non-pharmacological interventions to provide comfort (or related concepts): aromatherapy, reiki and therapeutic touch:28 aromatherapy, footsoak, and reflexology;48 aromatherapy;54 aromatherapy massage;49 massage therapy;43-46 noncontact therapeutic touch;57 music therapy;47,51-53,55,56 hypnotherapy;30 art therapy;31 and electromyography biofeedback-assisted relaxation.50The most implemented and evaluated interventions to provide comfort were music therapy (six studies)47,51-53,55,56 and massage therapy (four studies).43-46
Only three studies evaluated the total comfort provided by the interventions.28,43,55 The remaining studies evaluated comfort-related concepts: pain,28,31,44,45,49-52,54,56 anxiety,28,30,31,44,47,49,52-54 depression,28,30,31,47,49,52,54 stress,43,46,47 fatigue31,47,48 and well-being.31,51,52,54,57 None of the included studies evaluated suffering.
Table 4 shows the non-pharmacological interventions that implemented and evaluated to provide comfort.
Characteristics of non-pharmacological interventions
The frequency of interventions ranged from one to 14 sessions and their duration five to 60 minutes. Table 5 shows the characteristics of non-pharmacological interventions in studies included in this scoping review that were implemented and evaluated to provide comfort (or related concepts).
Contexts where non-pharmacological interventions were implemented and evaluated
This scoping review considered non-pharmacological interventions implemented and evaluated in PC settings, which included interventions specifically implemented and evaluated for home care patients, and hospice and PCU inpatients.
The majority of the analyzed interventions were implemented in PCUs28,31,46,48-50,52,57 and hospices.30,43,45,47,53,55,56 Only three interventions were implemented in home care.43,44,54
Table 6 shows the contexts where the non-pharmacological interventions included in this scoping review were implemented and evaluated.
Populations in which the non-pharmacological interventions were implemented and evaluated
Ten of the 18 analyzed interventions were implemented and evaluated exclusively in cancer patients,30,31,45-50,54,57 four in cancer and non-cancer patients,43,44,51,52 and two in non-cancer patients;53,56 two did not mention the participants' diagnosis.28,55
Ten of the 18 interventions were implemented and evaluated in people with IAD with a mean age of 60 years or older.30,45-49,51-54
Table 7 shows the results of studies included in this scoping review in relation to the populations and age of participants in which the non-pharmacological interventions were implemented and evaluated.
Discussion
The purpose of this scoping review was to examine and map non-pharmacological interventions implemented and evaluated to provide comfort in PC.
To address this question, 18 primary studies were included. Although it would have been ideal to include systematic reviews, none of those identified in the database search met all the inclusion criteria.
Although 12 reviews reached the full-text analysis phase, five of them were excluded after full-text reading because they reported data from interventions implemented and evaluated in contexts other than the PCU, hospice or home care (e.g. oncology department). The same applied to their population: four reviews were excluded after full-text reading because they included studies in which participants were not diagnosed with IAD (e.g. participants were cancer survivors). In addition, another review was excluded since it included studies addressing concepts (e.g. mood) which was not defined as an inclusion criterion in the protocol of this scoping review. Finally, two reviews were excluded because they were not systematic literature reviews, a necessary criterion for inclusion. The reference lists of these studies were analyzed, but no new studies were found.
It should also be noted that evaluation results are not required for the descriptive data necessary for the elaboration of a scoping review. However, the inclusion criteria defined in the protocol mention that "this scoping review considered all studies that address non-pharmacological interventions implemented and evaluated to provide comfort".40 As such, it was decided by consensus among the authors not to include the two studies58,59 that only mentioned the non-pharmacological intervention implemented, but without an evaluation of it (related to the concept but did not evaluate the intervention). In addition, one of the objectives of this scoping review was to inform future systematic reviews of the literature. Therefore, it would not be appropriate to guide future researchers to perform a systematic review on the effectiveness or meaningfulness of a certain non pharmacological intervention, when in reality there was no qualitative or quantitative evaluation of the intervention in the primary studies.
The reasons for excluding studies after full-text reading are presented in Appendix III.
Thirteen of the 18 studies included mentioned the study design.43-46,49-57 In the remaining five studies, the study design was identified by the review authors.28,30,31,47,48
An increase was observed in the number of non-pharmacological interventions implemented and evaluated to provide comfort since 2002. This may be explained by the fact that this was the year when the World Health Organization extended the definition of PC, emphasizing the importance of preventing and relieving suffering, promoting comfort and developing research to improve complex clinical situations.7
Non-pharmacological interventions implemented and evaluated to provide comfort to patients with IAD
Palliative care is the active, total care of patients, in which aggressive therapeutic interventions give way to intensive comfort measures,60,61 In this field, the development and implementation of non-pharmacological interventions has increased.27,62 However, although the main objective of PCUs is to provide comprehensive comfort care to the person with IAD, as mentioned in the results section, only three of the 18 included studies assessed the total level of comfort resulting from the interventions. This mapping has clearly identified the need for research on comprehensive comfort care provided through non-pharmacological interventions. It should be noted that previous studies have identified that the lack of scientific evidence on the effectiveness of non-pharmacological interventions is a barrier to their implementation.63,64
Another barrier to the implementation of non-pharmacological interventions is the inconsistency of results obtained in different studies on the same non-pharmacological intervention. For example, two studies included in this scoping review assessed the impact of therapeutic massage on stress levels,43,46 and reached differing results. The same applies to three studies on the effect of music therapy, which obtained divergent results in terms of anxiety and pain levels.51-53
The diversity of populations, contexts and characteristics of these interventions may help to explain the variability of results regarding some concepts. However, systematic reviews should be conducted in order to guide practice through the identification of the best available evidence on the effect of those interventions.
The following barriers to the implementation of non-pharmacological interventions were identified in these studies: the lack of scientific evidence on their effectiveness, the need to hire external professionals with specific training, and the financial cost for institutions.63,64
Guided imagery is one of the easiest and less expensive non-pharmacological interventions that nurses can implement, requiring little effort from patients. Moreover, the literature argues that guided imagery is associated with a significant increase in patient comfort in various clinical settings.65-71 However, none of the studies included in this scoping review had implemented and evaluated this intervention.
This scoping review revealed the lack of studies on the impact of this comfort intervention in PC, which clearly limits its implementation. If this intervention proves to be effective in this context, its implementation may translate into a significant increase in the comfort levels of patients with IAD. Therefore, primary studies should be carried out to implement and evaluate the effect of this intervention in PC.
Characteristics of non-pharmacological interventions implemented and evaluated to provide comfort to patients with IAD
The need to implement non-pharmacological interventions in PC that require little effort for participants was reinforced by Kolcaba, author of the Theory of Comfort.43 Given the multiple characteristics of the non-pharmacological interventions implemented in the included studies, it would be important to examine the reason why these prolonged and recurring interventions do not generate the opposite effect and promote discomfort.
Once again, Kolcaba23 advises that, even though proper comfort interventions are intentionally provided, comfort may not be sufficiently enhanced. In this case, nurses should analyze the characteristics of the interventions and the reasons for their ineffectiveness in providing the desired comfort.
Contexts where the non-pharmacological interventions were implemented and evaluated to provide comfort to patients with IAD
Although the person at the end of life may prefer dying at home,72 the reality is that this experience is increasingly occurring in a hospital environment. Hospitals are viewed as having better facilities and human resources, and better comfort and safety conditions when compared to the home. Additionally, since life expectancy is increasing, families often lack the ability to care for their sick relatives, thus leading to their hospital admission.73,74
These are some of the reasons why most of the analyzed interventions were implemented in PCUs28,31,46,48-50,52,57 and hospices.30,43,45,47,53,55,56 In addition, the difficulty in recruiting patients receiving PC at home and the low receptivity of family members has also hindered the development of studies in this context.43
Populations in which non-pharmacological interventions were implemented and evaluated to provide comfort to patients with IAD
According to the World Health Organization, PC should be provided to people facing problems associated with life-threatening cancer or non-cancer diseases. Indeed, a great majority of adults in need of PC die from cardiovascular diseases (38.5%) and cancer (34%), followed by chronic respiratory diseases (10.3%), HIV/AIDS (5.7%) and diabetes (4.5%).1
Since the early 1980 s, the need for PC for cancer patients has been increasingly acknowledged worldwide. More recently, there is increased awareness of the need for PC for other chronic diseases. However, there remains a huge unmet need for PC for these chronic (non-cancer) life-limiting conditions in most parts of the world.1
Worldwide, over 20 million people are estimated to require PC at the end of life every year. The majority (69%) are adults over 60 years.1
With the increased need for PC, there is also a need to improve patients' comfort levels, namely, through non-pharmacological interventions.23
For this reason, there is an urgent need to develop studies on the implementation and evaluation of non-pharmacological interventions that provide comfort to cancer and non-cancer patients.
Limitations of the included studies
Although the methodological quality of the included studies was not assessed, since it is not relevant for a scoping review, some limitations should be reported so as to provide valuable information to future research studies/systematic reviews. These limitations are related to small sample sizes,30,46,49,50,52,54 study designs,30,44,46,53,54 lack of assessment of the long-term impact of interventions,48,50 use of unclear measurement instruments,54 and differences in the number of sessions received by participants in the same study.44
These limitations hinder the rigorous assessment of the impact of non-pharmacological interventions on comfort and should be addressed since the lack of accurate scientific evidence on their effectiveness is a barrier to their implementation in PC.63
However, the difficulties associated with recruitment in studies with populations of patients with IAD should be taken into account.43,46,49,52,53
Another limitation of some included studies was the lack of information on the duration of the interventions28,30,55 or the time lapse between sessions.28,30,44,48,51,56,57 This aspect limited the analysis and mapping of the characteristics of the interventions described in the included studies.
Limitations of the scoping review
A limitation of this scoping review was the fact that only studies published in English, Portuguese and Spanish were included. Articles published in other languages could also have been important to this review. Another limitation was the fact that only studies conducted in home care settings, hospices and PCUs were included. Interventions implemented in all patients receiving PC (other hospital units or with day-care patients) could also have been important to this review.
Furthermore, since the objective of this scoping review was to examine and map non-pharmacological interventions implemented and evaluated to provide comfort in PC, no rating of methodological quality is provided and, therefore, recommendations for practice cannot be graded.
Conclusions
This scoping review aimed to map non-pharmacological interventions implemented and evaluated to provide comfort in PC and identify their characteristics, contexts and populations.
Ten non-pharmacological interventions were identified. Music therapy and massage therapy were the most common interventions. Characteristics differed significantly across interventions and even in the same intervention, both in terms of number of sessions (between one and 14 sessions) and their duration (between five and 60 minutes). Interventions were implemented mostly in PCUs and hospices, and in patients with cancer diagnosis. These data raise questions for future primary studies and systematic reviews.
Implications for research
Future primary studies should clearly identify characteristics of the interventions, type of study, context and patient diagnosis.
Furthermore, future primary research should perform in-depth qualitative studies on the experience of patients who have received non-pharmacological interventions and focus on the implementation of interventions in cancer and non-cancer patients, and patients receiving PC at home.
Since the main purpose of PC is to provide the maximum comfort possible to patients with IAD, further research needs to be undertaken to evaluate the effectiveness of non-pharmacological interventions and their impact on comfort.
Systematic reviews on the effect of massage therapy and music therapy should be performed.
Due to the existence of several primary studies on massage therapy and music therapy that have different characteristics and report different results, systematic reviews on the effects of massage therapy and music therapy should be performed to determine the best available evidence about their effect on comfort and to guide clinical practice.
Acknowledgements
The authors gratefully acknowledge the support from the Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC), the Foundation for Science and Technology (FCT) and Translation Department of ESEnfC for English language editing.
Appendix I: Search strategy
PubMed - search conducted on November 24th, 2015
CINAHL Plus - search conducted on November 23th, 2015
Scopus - search conducted on November 24th, 2015
Banco de teses da CAPES (http://www.capes.gov.br) - search conducted on November 24th, 2015
LILACS - search conducted on November 24th, 2015
Library, Information Science and Technology Abstracts - search conducted on November 24th, 2015
PsycINFO - search conducted on November 24th, 2015
Teseo - Base de datos de Tesis Doctorales - search conducted on November 24th, 2015
TDX - Tesis Doctorals en Xarxa - search conducted on November 24th, 2015
Cochrane Library - search conducted on November 23th, 2015
JBI Database of Systematic Reviews and Implementation Reports - search conducted on November 24th, 2015
RCAAP - Repositorio Cientifico de Acesso Aberto de Portugal - search conducted on November 24th, 2015
ProQuest - Nursing and Allied Health Source Dissertations - search conducted on November 24th, 2015
SciELO - search conducted on November 24th, 2015
Appendix II: Data extraction instrument
Appendix III: List of excluded studies after eligibility assessment based on full-text reading
Ahmed HE, Craig WF, White PF, Huber P. Percutaneous electrical nerve stimulation (PENS): A complementary therapy for the management of pain secondary to bony metastasis. Clin J Pain. Dept. of Anesth. and Pain Management, Eugene McDermott Ctr. for Pain Mgmt., Univ. TX Southwestern Med. Ctr. D., Dallas, TX, United States; 1998;14(4):320-3.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Archie P, Bruera E, Cohen L. Music-based interventions in palliative cancer care: a review of quantitative studies and neurobiological literature. Support Care Cancer. Germany; 2013 Sep;21(9):2609-24.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Ben-Arye E, Israely P, Baruch E, Dagash J. Integrating family medicine and complementary medicine in cancer care: A cross-cultural perspective. Patient Educ Couns. 2014;97(1):135-9.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Benney S, Gibbs V. A literature review evaluating the role of Swedish massage and aromatherapy massage to alleviate the anxiety of oncology patients. Radiography. 2013;19(1):35-41.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Bullock M. Reiki: a complementary therapy for life. Am J Hosp Palliat Care. United States; 1997;14(1):31-3.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Elkis-Abuhoff D, Goldblatt R, Gaydos M, Corrato S. Effects of clay manipulation on somatic dysfunction and emotional distress in patients with Parkinson's disease. Art Ther J Am Art Ther Assoc. 2008;25(3):122-8.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Dunwoody L, Smyth A, Davidson R. Cancer patients' experiences and evaluations of aromatherapy massage in palliative care. Int J Palliat Nurs. 2002;8(10):497-504.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Engelman SR. Palliative care and use of animal-assisted therapy. Omega. United States; 2013;67(1-2):63-7.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Fleming U. Relaxation therapy for far-advanced cancer. Practitioner. England; 1985 May;229(1403):471-5.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Gallagher LM, Lagman R, Walsh D, Davis MP, Legrand SB. The clinical effects of music therapy in palliative medicine. Support Care Cancer. 2006;14(8):859-66.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Gambles M, Crooke M, Wilkinson S. Evaluation of a hospice based reflexology service: a qualitative audit of patient perceptions. Eur J Oncol Nurs. Scotland; 2002 Mar;6(1):37-44.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Gutgsell KJ, Schluchter M, Margevicius S, DeGolia PA, McLaughlin B, Harris M, et al. Music therapy reduces pain in palliative care patients: a randomized controlled trial. J Pain Symptom Manage. 2013;45(5):822-31.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Hokka M, Kaakinen P, Polkki T. A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer. J Adv Nurs. England; 2014 Sep;70(9):1954-69.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Huntley A, Ernst E. Complementary and alternative therapies for treating multiple sclerosis symptoms: a systematic review. Complement Ther Med. 2000;8(2):97-105.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Jane S-W, Wilkie DJ, Gallucci BB, Beaton RD, Huang H-Y. Effects of a full-body massage on pain intensity, anxiety, and physiological relaxation in Taiwanese patients with metastatic bone pain: a pilot study. J Pain Symptom Manage. 2009 Apr;37(4):754-63.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Krout RE. The effects of single-session music therapy interventions on the observed and self-reported levels of pain control, physical comfort, and relaxation of hospice patients. Am J Hosp Palliat Care. 2001;18(6):383-90.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Kutner JS, Smith MC, Corbin L, Hemphill L, Benton K, Mellis BK, et al. Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial. Ann Intern Med. 2008;149(6):369-79.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Kyle G. Evaluating the effectiveness of aromatherapy in reducing levels of anxiety in palliative care patients: results of a pilot study. Complement Ther Clin Pract. 2006 May;12(2):148-55.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Lafferty WE, Downey L, McCarty RL, Standish LJ, Patrick DL. Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation. Complement Ther Med. 2006 Jun;14(2):100-12.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Lopez-Sendin N, Alburquerque-Sendin F, Cleland JA, Fernandez-de-las-Penas C, Lopez-Sendin N, Alburquerque-Sendin F, et al. Effects of physical therapy on pain and mood in patients with terminal cancer: a pilot randomized clinical trial. J Altern Complement Med. United States; 2012 May;18(5):480-6.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Magill L, Berenson S. The conjoint use of music therapy and reflexology with hospitalized advanced stage cancer patients and their families. Palliat Support Care. 2008 Sep;6(3):289-96.
Reason for exclusion: This study did not meet the inclusion criteria (context).
McDonald A, Burjan E, Martin S. Yoga for patients and carers in a palliative day care setting. Int J Palliat Nurs. England; 2006 Nov;12(11):519-23.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Mitchinson A, Fletcher CE, Kim HM, Montagnini M, Hinshaw DB. Integrating massage therapy within the palliative care of veterans with advanced illnesses: an outcome study. Am J Hosp Palliat Care. United States; 2014 Feb;31(1):6-12.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Partridge RA, Matulonis UA, Rosenthal DS, Penson RT. Why use complementary and alternative medicine during cancer treatment? Patient perspectives on acupuncture and other alternative therapies. J Cancer Integr Med. 2005;3(1):27-37.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Pollak KI, Lyna P, Bilheimer A, Porter LS. A brief relaxation intervention for pain delivered by palliative care physicians: A pilot study. Palliat Med. Cancer Control and Population Sciences, Duke Cancer Institute, Durham, NC, United States: SAGE Publications Ltd; 2015 Jun 1;29(6):569-70.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Serfaty M, Wilkinson S, Freeman C, Mannix K, King M. The ToT study: helping with Touch or Talk (ToT): a pilot randomised controlled trial to examine the clinical effectiveness of aromatherapy massage versus cognitive behaviour therapy for emotional distress in patients in cancer/palliative care. Psychooncology. 2012 May;21(5):563-9.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Singh BB, Wu W-S, Hwang SH, Khorsan R, Der-Martirosian C, Vinjamury SP, et al. Effectiveness of acupuncture in the treatment of fibromyalgia. Altern Ther Health Med. United States; 2006;12(2):34-41.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Smithson J, Britten N, Paterson C, Lewith G, Evans M. The experience of using complementary therapies after a diagnosis of cancer: a qualitative synthesis. Health (London). England; 2012 Jan;16(1):19-39.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Spiller J. Acupuncture, ketamine and piriformis syndrome - a case report from palliative care. Acupunct Med. England; 2007 Sep;25(3):109-12.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Toth M, Kahn J, Walton T, Hrbek A, Eisenberg DM, Phillips RS. Therapeutic Massage Intervention for Hospitalized Patients with Cancer: A Pilot Study. Altern Complement Ther. 2003 Jun;9(3):117-24.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Waissengrin B, Urban D, Leshem Y, Garty M, Wolf I. Patterns of Use of Medical Cannabis Among Israeli Cancer Patients: A Single Institution Experience. J Pain Symptom Manage. 2015 Feb;49(2):223-30.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Wilkinson S, Aldridge J, Salmon I, Cain E, Wilson B. An evaluation of aromatherapy massage in palliative care. Palliat Med. 1999 Sep;13(5):409-17.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Yamamoto K, Nagata S. Physiological and psychological evaluation of the wrapped warm footbath as a complementary nursing therapy to induce relaxation in hospitalized patients with incurable cancer: a pilot study. Cancer Nurs. 2011 Jan;34(3):185-92.
Reason for exclusion: This study did not meet the inclusion criteria (context).
Hsu C-C, Chen M-J, Tseng Y-H, Hwang S-F, Huang H-M. Improving constipation in patients at terminal stage: A pilot study on the efficacy of using abdominal meridian massage with essential oil. J Nurs Healthc Res. Palliative Care Ward, Veterans General Hospital-Taichung, Taiwan: Taiwan Nurses Association; 2009;5(4):256-64.
Reason for exclusion: This study did not meet the inclusion criteria (language).
Chang SY. Effects of aroma hand massage on pain, state anxiety and depression in hospice patients with terminal cancer. Taehan Kanho Hakhoe Chi. 2008 Aug;38(4):493-502.
Reason for exclusion: This study did not meet the inclusion criteria (language).
Safrai MB. Art Therapy in Hospice: A Catalyst for Insight and Healing. Art Ther. 2013 Jul 3;30(3):122-9.
Reason for exclusion: This study did not meet the inclusion criteria (related to the concept but did not evaluate the intervention).
Cooksley V. An integrative aromatherapy intervention for palliative care. Int J Aromather. 2003;13(2-3):128-37.
Reason for exclusion: This study did not meet the inclusion criteria (related to the concept but did not evaluate the intervention).
Zadow L. Utilising hypnosis for palliative care: The case of PB. Aust J Clin Exp Hypn. 22 Norman Road, Yatala Vale, SA 5126, Australia; 2004;32(2):170-88.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
Buday KM. Engage, empower, and enlighten: Art therapy and image making in hospice care. Prog Palliat Care. 2013 May;21(2):83-8.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
Freeman L, Caserta M, Lund D, Rossa S, Dowdy A, Partenheimer A. Music thanatology: Prescriptive harp music as palliative care for the dying patient. Am J Hosp Palliat Med. 2006 Mar 1;23(2):100-4.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
Meek SS. Effects of slow stroke back massage on relaxation in hospice clients. Image J Nurs Scholarsh. United Kingdom: Blackwell Publishing; 1993;25(1):17-21.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
MacDonald JM, Barrett D. Companion animals and well-being in palliative care nursing: a literature review. J Clin Nurs. 2015 Nov.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
Nelson JP. Being in tune with life: complementary therapy use and well-being in residential hospice residents. J Holist Nurs. United States; 2006 Sep;24(3):152-61.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
Meek S. Perceptions and selected physiological effects of slow stroke back massage in hospice clients. University of Texas - Austin; 1991.
Reason for exclusion: This study did not meet the inclusion criteria (concept).
Akechi T, Okuyama T, Onishi J, Morita T, Furukawa TA. Psychotherapy for depression among incurable cancer patients. Cochrane Database Syst Rev. Department of Psychiatry, Nagoya City University Medical School, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467 8601, Japan; 2008;(2).
Reason for exclusion: This study did not meet the inclusion criteria (population).
Berger AM, Yennu S, Million R. Update on interventions focused on symptom clusters: what has been tried and what have we learned? Curr Opin Support Palliat Care. United States; 2013 Mar;7(1):60-6.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Bowers TA, Wetsel MA. Utilization of music therapy in palliative and hospice care: An integrative review. J Hosp Palliat Nurs. School of Nursing, Clemson University, 528 Owl Nest Rd, Landrum, SC 29356, United States: Lippincott Williams and Wilkins; 2014 Jun;16(4):231-9.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Caires JS, Andrade TA de, Amaral JB do, Calasans MT de A, Rocha MD da S. A utilizacao das terapias complementares nos cuidados paliativos: beneficios e finalidades. Cogitare Enferm. Departamento de Enfermagem da Universidade Federal do Parana; 2014;19(3):514-20.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Chan CWH, Richardson A, Richardson J. Managing symptoms in patients with advanced lung cancer during radiotherapy: results of a psychoeducational randomized controlled trial. J Pain Symptom Manage. 2011 Feb;41(2):347-57.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Choi T-Y, Lee MS, Kim T-H, Zaslawski C, Ernst E. Acupuncture for the treatment of cancer pain: a systematic review of randomised clinical trials. Support Care Cancer. Germany; 2012 Jun;20(6):1147-58.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Downey L, Diehr P, Standish LJ, Patrick DL, Kozak L, Fisher D, et al. Might massage or guided meditation provide "means to a better end"? Primary outcomes from an efficacy trial with patients at the end of life. J Palliat Care. 2009;25(2):100-8.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Harlow T, Jones P, Shepherd D, Hong A, Walker G, Greaves C. Hypnotherapy for relief of pain and other symptoms in palliative care patients: A pilot study. Contemp Hypn Integr Ther. Hospiscare (Exeter and District Hospice), United Kingdom: Crown House Publishing; 2015;30(4):163-74.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Kaufman K, Salkeld EJ. Home hospice acupuncture: a preliminary report of treatment delivery and outcomes. Perm J. United States; 2008;12(1):23-6.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Leng G. A year of acupuncture in palliative care. Palliat Med. England; 1999 Mar;13(2):163-4.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Mansky PJ, Wallerstedt DB. Complementary medicine in palliative care and cancer symptom management. Cancer J. 2006;12(5):425-31.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Posadzki P, Moon T-W, Choi T-Y, Park T-Y, Lee MS, Ernst E. Acupuncture for cancer-related fatigue: a systematic review of randomized clinical trials. Support Care Cancer. Germany; 2013 Jul;21(7):2067-73.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Teut M, Dietrich C, Deutz B, Mittring N, Witt CM. Perceived outcomes of music therapy with Body Tambura in end of life care - A qualitative pilot study. BMC Palliat Care. Institute for Social Medicine, Epidemiology and Health Economics, Charite Universitatsmedizin Berlin, Luisenstr. 57, Berlin 10117, Germany: BioMed Central Ltd.; 2014;13(1).
Reason for exclusion: This study did not meet the inclusion criteria (population).
Vandergrift A. Use of complementary therapies in hospice and palliative care. Omega. 2013 Jan;67(1-2):227-32.
Reason for exclusion: This study did not meet the inclusion criteria (population).
Bowers LJ. To what extent does aromatherapy use in palliative cancer care improve quality of life and reduce levels of psychological distress? A literature review. Int J Aromather. 2006;16(1):27-35.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Collette N. Patient's plastic expression of pain. Med Paliativa. Departamento de Pintura, Facultad de Bellas Artes, Universitat Politecnica de Valencia, Spain; 2004;11(3):141-7.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Collette N. Arteterapia y cancer. Psicooncologia. Hospital de la Santa Creu i Sant Pau, Unidad de Cuidados Paliativos, Institut de Recerca, Calle Sant Quinti, 90, 08025 Barcelona, Spain; 2011 Jun 1;8(1):81-99.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Dias GA. A massagem como promotora de conforto a pessoa em fim de vida. Relatorio de Estagio para obtencao do grau de Mestre em Enfermagem a Pessoa em Processo de Doenca na Comunidade. 2012.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Gamus D, Kedar A, Kleinhauz M. Hypnosis in palliative care. Prog Palliat Care. 2012 Nov;20(5):278-83.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Hilliard RE. Music therapy in hospice and palliative care: A review of the empirical data. Evidence-based Complement Altern Med. Music Department, State University of New York at New Paltz, New Paltz, NY, United States; 2005;2(2):173-8.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Kraft K. CAM for depression, anxiety, grief, and other symptoms in palliative care. Prog Palliat Care. 2012 Nov;20(5):272-7.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Miles P. Palliative care service at the NIH includes Reiki and other mind-body modalities. Adv Mind Body Med. United States; 2004;20(2):30-1.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Seki NH, Galheigo SM. The use of music in palliative care: humanizing care and facilitating the farewell. Interface - Comun Saude, Educ. 2010;14(33):273-84.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Price A, Hotopf M. The treatment of depression in patients with advanced cancer undergoing palliative care. Curr Opin Support Palliat Care. United States; 2009 Mar;3(1):61-6.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Leow Q, Drury V, Poon WH. Experience of terminally ill patients with music therapy: a literature review. Singapore Nurs J. 2010;37(3):48-52.
Reason for exclusion: This study did not meet the inclusion criteria (type of study).
Wilkinson S. Aromatherapy and massage in palliative care. Int J Palliat Nurs. 1995;1(1):21-30.
Reason for exclusion: Compliance with the inclusion criteria could not be determined (full-text could not be obtained from other research centers and the available databases, and the author did not reply to our contact).
Pauli R. How does massage therapy make a difference in palliative care? J Aust Assoc Massage Ther. 2011;9(1):13-5.
Reason for exclusion: Compliance with the inclusion criteria could not be determined (full-text could not be obtained from other research centers and available databases, and author could not be contacted).
Corner J, Cawley N, Hildebrand S. An evaluation of the use of massage and essential oils on the wellbeing of cancer patients. Int J Palliat Nurs. 1995;2(1):67-73.
Reason for exclusion: Compliance with the inclusion criteria could not be determined (full-text could not be obtained from other research centers and available databases, and author could not be contacted).
Appendix IV: Extraction instrument detailing characteristics of included studies
References