Understanding Evidence Based Practice - Evidence Based Practice - Evidence Training

Evidence contributing to decision-making in palliative care

Evidence-based practice (EBP) has been defined as ‘integrating the best available research evidence with clinical expertise and the patient’s unique values and circumstances’. [1] More recent definitions are very similar to this one from Sackett but also emphasise the importance of the clinical situation and patient role. [2] The term 'evidence-based' is also often replaced by or used interchangeably with 'evidence-informed' to reflect that it is not the sole-determinant of decision-making. [3,4] Whichever term is used the value of considering evidence in care decision-making remains. [3]

In practice, EBP begins with identification of a clinical problem or issue of a patient and integrates these distinct elements as part of the decision-making process.

Starting point

A clinical problem or issue of a patient.

Goal

Evidence-based health care combines the best available evidence, clinical situation of the patient, patient preferences and actions, all bound together by clinical experience. [2]

Role of evidence

Where available, relevant evidence informs clinical decisions when dealing with patient problems and issues.

Sackett, Rosenberg, et al highlighted the essential aspects of evidence based medicine in their 1996 overview Evidence based medicine: what it is and what it isn't (544kb pdf). EBP can be undertaken by an individual clinician to improve care outcomes. Providing an evidence-based approach to clinical care requires the health professional to be able to:

Understand the relationships between research and strength of evidence
Access and appraise evidence
Determine its applicability with regard to a particular patient’s context and wishes
Make care decisions together with patients based on integration of evidence with clinical expertise and the patient’s preferences.

Beginning with observation of an issue or problem EBP takes a systematic approach to the use of evidence. There are five key EBP steps towards this:

Ask
Acquire
Appraise (& synthesise)
Apply
Assess

EBP in palliative care

For palliative care, as with other disciplines, the development of evidence-based practice requires access to good quality and relevant evidence. Locating relevant research evidence in palliative care can be challenging. However, EBP is a multicomponent model and clinical reasoning will help you to integrate the best available evidence with clinical experience (including that of other health professionals) and patient values and circumstances.

Challenges in accessing and applying evidence in palliative care include:

As this is a multidisciplinary field of practice, the literature and evidence base for palliative care can be complex with potentially useful material in many journals and bibliographic databases making identification and retrieval difficult.
Clinical issues may not yet have been the subject of targeted research for a palliative population leaving clinicians reliant on evidence of uncertain relevance.
Qualitative investigations are common in many of the disciplines that contribute to palliative care, and they can utilise different methodologies and approaches. This can add to the complexities in comparing and combining studies. they can also remind clinicians to address the individual's specific life context and care needs.
Palliative care is provided across a wide range of care settings for people with malignant and non-malignant disease. Therefore, you may encounter specific issues relating to the transferability and generalisability of evidence between sites of care delivery, underlying disease processes and patient groups.
The palliative care focus on optimal symptom control and quality of life as an outcome rather than cure also means that there must be a clear understanding of patient wishes and preferences that align with the best available evidence on treatment and care options in determining the plan for care.

Key reading

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71-2. doi: 10.1136/bmj.312.7023.71.
BMJ Best Practice, BMJ Evidence Based Practice Toolkit – what is EBM?
Oxford Centre for Evidence Based Medicine - glossary of terms.