Skip to main content
NCBI home page
Florence Nightingale Journal of Nursing logoLink to Florence Nightingale Journal of Nursing
. 2024 Feb 1;32(1):90–98. doi: 10.5152/FNJN.2023.23043

Evidence-Based Nonpharmacological Symptom Management of Palliative Care in Advanced and Metastatic Cancer Patients: A Systematic Review

Berkay Alikan 1,✉, Gülbeyaz Can 1
PMCID: PMC11059571  PMID: 39555907

Abstract

Aim:

The aim of this systematic review is to provide reliable, high-quality data with an evidence-based, up-to-date overview of the use of nonpharmacologic interventions in the management of symptoms in advanced cancer patients with metastatic disease.

Method:

A comprehensive literature search was performed by searching PubMed, EBSCO, Cochrane, and Google Scholar databases. “Nonpharmacologic,” “palliative care,” and “cancer” were the three main terms combined with the main symptoms of cancer palliative care such as “pain,” “fatigue,” “nausea and vomiting,” “psychosocial distress,” “loss of appetite,” “dyspnea,” “constipation,” and “drowsiness,” and each symptom was searched separately.

Results:

Thirteen studies were included in this systematic review with a total of 1975 participants. Three of the studies examined “fatigue,” three examined “quality of life,” one examined “sleep,” three examined “dyspnea,” two examined “depression,” and one examined “pain.” To manage these symptoms, three of the studies included in the systematic review used “patient education,” three of the studies used “exercise,” three of the studies used “fan therapy,” and the remaining studies used “reflexology,” “cognitive behavioral therapy,” and “occupational therapy.”

Conclusion:

Number of studies done regarding the advanced and metastatic cancer patients and their symptom management through nonpharmacological methods are low, which makes it difficult to draw decisive conclusions.

Keywords: Advanced cancer, nursing, symptom management

Introduction

The word palliative derives from the Latin word pallium, which means cloak or to cloak. Palliative care does not aim to prolong a patient’s life or treat them but to “cloak” the patient’s symptoms to allow them to die peacefully. World Health Organization (WHO) stated that palliative care prevents and relieves suffering through the early recognition, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual (World Health Organization, 2020). Thus, the correct assessment and treatment of symptoms that affect the patient’s quality of life (QoL) is critical to achieving the main goals of palliative care.

World Health Organization estimates that 56.8 million people will need palliative care in 2020 (World Health Organization, 2020). However, one study has shown that this number will increase to more than 100 million by 2040 (ElMokhallalati et al., 2020). The need for palliative care is increasing as the global population ages and chronic diseases such as cancer, cardiovascular disease, renal failure, and respiratory disease become more prevalent (ElMokhallalati et al., 2020). Most patients who seek palliative care are patients with metastatic cancer, who are usually at the end of life. Patients with metastatic cancer suffer from a variety of symptoms such as pain, fatigue, nausea, depression, anxiety, drowsiness, loss of appetite, malaise, dyspnea, etc., which significantly increases their need for palliative care (Bruera et al., 1991; Fadol et al., 2021; Finucane et al., 2021; Hausner et al., 2021; Isenberg et al., 2022; Kennedy et al., 2019; Wilson et al., 2020).

Due to the nature of cancer itself and current treatment options, it is inevitable that patients diagnosed with cancer will suffer from symptoms. Current evidence shows that nearly 90% of advanced and metastatic cancer patients suffer from chronic pain. After pain, the most common symptoms are fatigue (68–91%) and nausea/vomiting (47.4–77%) (Deandrea et al., 2014; Oechsle et al., 2013, 2014; Süren et al., 2015; Uysal, 2015). Different cancers may cause the same symptom by completely different mechanisms. Nausea in patients with advanced lung cancer can sometimes be caused by either brain metastases, while nausea in patients with advanced colorectal cancer can be caused by bowel obstruction (Wickham, 2020). Although these symptoms differ in nature, they have in common that they are multidimensional and severely affect patients’ QoL (Hui & Bruera, 2017). Effective management of these symptoms is important because this effective management increases patients’ QoL while improving their participation in treatment.

Symptom management is the most important part of palliative care because effective symptom control, provided by a specialized and experienced team of healthcare providers, helps patients achieve a peaceful death. Numerous pharmacologic and nonpharmacologic interventions to control patients’ symptoms can be found in the literature with varying degrees of success (Armstrong et al., 2020; Chan, 2018; Ferrell et al., 2017; Zeng et al., 2018). Studies examining the efficacy of nonpharmacologic approaches generally do not include patients with advanced and metastatic cancer. These patients have a greater symptom burden, and the psychosocial aspect of these patients and their families presents an obstacle that is not only difficult to overcome but also very delicate to manage (Higginson, 2016). There is also evidence that many patients choose to spend their last days at home as their condition worsens, which presents another obstacle for research regarding this issue (Lin et al., 2023). For these reasons, there is insufficient evidence on nonpharmacologic symptom control in patients with advanced and metastatic cancer.

The aim of this systematic review is to provide reliable, high-quality data with an evidence-based, up-to-date overview of the use of nonpharmacologic interventions in the management of symptoms in advanced cancer patients with metastatic disease.

Methods

Study Design

Based on the knowledge gaps outlined in the introduction of this article, the current evidence on the effect of nonpharmacologic interventions on symptom management of palliative cancer patients with advanced or metastatic disease is not enough and it should be addressed. To address this issue, this study conducted a methodological systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher, 2009).

Inclusion and Exclusion Criteria

The criteria for inclusion of studies are as follows:

  1. Randomized controlled trials evaluating the effects of nonpharmacologic interventions on symptom management in patients with advanced or metastatic cancer.

  2. Randomized controlled trials investigating the effects of nonpharmacologic interventions on pain, fatigue, nausea and vomiting, psychosocial distress, loss of appetite, dyspnea, constipation, and drowsiness.

  3. Randomized controlled trials using placebo or no treatment as a comparation to the intervention.

  4. Randomized controlled trials that has been published in 2013 and after.

  5. Randomized controlled trials with a JADAD score of 3 and above.

The criteria for exclusion of studies are as follows:

  1. Randomized controlled trials which doesn’t have a solely cancer patient participants, or randomized controlled trials without a solely advanced and metastatic cancer study group

  2. Randomized controlled trials that are not in English or Turkish

  3. Randomized controlled trials that have been published earlier than 2013.

  4. Randomized controlled trials that doesn’t have a clear description of the intervention done.

  5. Randomized controlled trials with a JADAD score below 3.

Search Strategy

A comprehensive literature search was performed by searching PubMed, EBSCO, Cochrane, and Google Scholar databases. “Nonpharmacologic,” “palliative care,” and “cancer” were the three main terms combined with the main symptoms of cancer palliative care such as “pain,” “fatigue,” “nausea and vomiting,” “psychosocial distress,” “loss of appetite,” “dyspnea,” “constipation,” and “drowsiness,” and each symptom was searched separately. Similar keywords such as “complementary medicine,” “alternative medicine,” and “hospice care” were also used to search the Google Scholar and EBSCO databases. Filters for the time period from 2013 to 2023, study type randomized control trial, and languages English and Turkish were applied after entering the keywords to narrow the results.

The level of evidence of studies included in this systematic review was determined depending on Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice, 2nd edition, by Melnyk and Overholt (Table 1) (Melnyk & Overholt, 2011).

Table 1.

The Melnyk Level of Evidence Classification (Melnyk & Overholt, 2011)

Level of Evidence Type of Study
I Systematic review and meta-analysis of RCTs; clinical guidelines based on systematic reviews or meta-analyses
II One or more RCTs
III Controlled trial (no randomization)
IV Case-control or cohort study
V Systematic review of descriptive and qualitative studies
VI Single descriptive or qualitative study
VII Expert opinion
Open in a new tab

Note: RCT = randomized controlled trial.

Study Selection, Data Extraction, and Analysis

After the comprehensive search, a total of 1378 research papers were initially found. There were 654 duplicates that were removed, and the abstracts of the remaining 724 studies were reviewed. A total of 652 studies were excluded after examining the title and abstract. Three of the studies were removed because they were written in a language other than Turkish or English; 52 studies were removed because their study group either did not include patients with advanced and metastatic cancer or included a mixture of early-stage patients and patients with advanced and metastatic cancer, and one study was removed because it didn’t have a clear description of the intervention done. After all studies were screened and reviewed, five studies were excluded because their JADAD score was less than 3. JADAD Score system, is a numerical system to determine the methodological quality of a clinical trial by judging the effectivenes of blinding therefore decreasing or removing bias. The main reason for excluding studies with a JADAD score of less than 3 was to exclude studies of low quality in terms of the aim of this systematic review. After this exclusion process, 11 studies remained to be included in this systematic review (Figure 1).

Figure 1.

Figure 1

Open in a new tab

PRISMA Flowchart for Study Selection.

Results

Characteristics of Studies

Thirteen studies were included in this systematic review, four studies were published in 2019, three in 2017, two in 2018, two in 2016, one in 2020, and one in 2013. The studies included in this systematic review had a total of 1975 participants, 1026 participants were randomly assigned to the control group, and 949 participants were randomly assigned to the intervention group. The median of the patients in the control group was 49 and 46 for the intervention group, respectively. The median of the patients in all included studies was 46.5.

Three of these studies had a JADAD score of 5, two of them had a JADAD score of 4, and six of them had a JADAD score of 3. The studies included in this systematic review examined various symptoms both alone and in combination with other symptoms, as well as various nonpharmacologic approaches to manage these symptoms. Three of the studies examined “fatigue,” three examined “quality of life,” one examined “sleep,” three examined “dyspnea,” two examined “depression,” and one examined “pain.” To manage these symptoms, three of the studies included in the systematic review used “patient education,” three of the studies used “exercise,” three of the studies used “fan therapy,” and the remaining studies used “reflexology,” “cognitive behavioral therapy,” and “occupational therapy.”

Management of Fatigue

The effect of exercise on fatigue management was assessed in two of the 11 studies and one study assessed the exercise against cognitive behavioral therapy (CBT) on fatigue management. In the first study, an RCT, performed by Cheville et al., in 2013 for the effect of incremental walking and home-based training on fatigue management with 66 patients (level of evidence II). In this study, participants done incremental walking and resistance-based home training for 8 weeks found to be effective for both fatigue and sleep (Cheville et al., 2013) In the second study, an RCT, performed by Wiskemann et al. in 2016 with an attendance of 150 patients (level of evidence II). In this study, a resistance and endurance training was done three times a week for 12 weeks and it was found to be effective for the management of fatigue and QoL (Wiskemann et al., 2016). In the third study, an RCT performed by Poort et al. in 2020 with an attendance of 130 patients. In this study, participants done either CBT less than 10, 1 hour individual sessions or graded exercise therapy (GET), 2 hour sessions for 12 weeks (level of evidence II). Cognitive behavioral therapy improved both the fatigue and QoL; on the other hand, GET did not improve the fatigue of the patients (Poort et al., 2020).

Studies done by Wiskemann et al. and Cheville et al. did not report any adverse events. Study of Poort et al. (2020) reported adverse events but didn’t explain the adverse events.

Management of Quality of Life

Two of the 11 studies examined patient educations efficacy on QoL, one of the studies examined reflexology and one of the studies examined the efficacy of exercise on QoL. In the first study, an RCT was performed by Wiskemann et al. in 2016 with an attendance of 150 patients (level of evidence II). In this study, a resistance and endurance training were done three times a week for 12 weeks and it was found to be effective for the management QoL and fatigue (Wiskemann et al., 2016). The second study, an RCT, was performed by Epstein et al. in 2016 with an attendance of 383 patients (level of evidence II). In this study, a patient education lasting 60 minutes for 6 months was found to be effective on improving QoL of patients (Epstein et al., 2016). The third study, a multicenter RCT, was performed by Franciosi et al. in 2019 with an attendance of 281 patients (level of evidence II). In this study, a consultation and visit program which lasts 45–60 minutes for the initial visit and 20–40 minutes for following visits for 24 weeks was found to be effective for improving QoL on patients (Franciosi et al., 2019). The fourth study, an RCT, was performed by Sikorskii et al., in 2020 with an attendance of 209 patients (level of evidence II). In this study, a reflexology session of 15 minutes for each foot for at least once a week for four consecutive weeks found to be not effective on QoL of the patients (Sikorskii et al., 2020).

The study of Franciosi et al. reported that patient education was more effective when following consultation visits or phone calls are made to the patients regarding their education. None of the included studies reported any adverse events during their interventions.

Management of Sleep

The effect of exercise on sleep was assessed in one of the 11 studies. The study, an RCT, performed by Cheville et al. in 2013 for the effect of incremental walking and home-based training on sleep with 66 patients (level of evidence II). In this study, participants done incremental walking and resistance-based home training for 8 weeks found to be effective for both sleep and fatigue (Cheville et al., 2013). No adverse events were reported on this study.

Management of Dyspnea

The effect of handheld fan or only fan on dyspnea management was assessed in three of the 11 studies. In the first study, a parallel arm RCT, performed by Kako et al. in 2018 for the effect of fan on dyspnea management during the hospital stay was assessed with the attendance of 40 patients (level of evidence II). In this study, a 5-minute fan therapy, from the patient’s preferred distance, found to be effective in management of short-term dyspnea (Kako et al., 2018). In the second study, a phase 2 clinical trial, performed by Wong et al. in 2017 for to assess the clinical feasibility and outcomes of fan on dyspnea management of Chinese patients with advanced cancer with 30 patients (level of evidence II). In this study, a 5-minute fan therapy with a low flow rate was directed at the patient’s face from the patient’s preferred distance, found to be effective in management of short-term dyspnea (Wong et al., 2017). In the third study, a randomized controlled experimental study, performed by Kocatepe et al. in 2021 using a handheld fan to manage dyspnea with the attendance of 96 patients (level of evidence II). In this study, a 5-minute fan therapy from 15 cm with a flow velocity of 4 km/h was found to be effective on dyspnea (Kocatepe et al., 2021).

No adverse effects as well as no changes on metabolic parameters were reported in neither of the three studies, but the study of Wong et al., (2017) reported a concern of the patients which was getting a cold or getting headaches from the fan therapy.

Management of Depression

The efficacy of patient education on depression was assessed by two of the 11 studies. The first study, a multicenter randomized clinical trial performed by Franciosi et al. in 2019 with an attendance of 281 patients (level of evidence II). In this study, a consultation and visit program which lasts 45–60 minutes for the initial visit and 20–40 minutes for following visits for 24 weeks was found to be effective for improving QoL but not effective for depression (Franciosi et al., 2019) The second study, a pilot randomized controlled clinical trial, performed by Carmo et al. in 2017 with an attendance of 60 patients (level of evidence II). In this study, neither CBT 90 days with five weekly individual sessions nor early palliative care was found to be effective on management of depression (do Carmo et al., 2017). None of the studies reported any adverse events.

Management of Pain

The effect of reflexology on pain is assessed in one of the 11 studies. The study, an RCT, was performed by Sikorskii et al. in 2019 with an attendance of 209 patients (level of evidence II). In this study, a reflexology session of 15 minutes for each foot for at least once a week for four consecutive weeks found to be effective on pain (Sikorskii et al., 2020) (Table 2).

Table 2.

Characteristics of Studies

Researcher Name and Publishment Year JADAD Score Symptom Intervention Intervention Group Control Group Method Outcome
Poort et al. (2020) 3 Fatigue CBT and exercise 42 42 CBT, less than 10 individual 1 hour sessions, 12 weeks, hospital Improvement on fatigue and QoL
46 GET, 2 hour supervised programs, 12 weeks, hospital, or local physiotherapy center No improvement
Standard care
Cheville et al. (2013) 3 Physical activity level, fatigue, and sleep quality Exercise 36 30 REST, two sets of five exercise routines 10 reps each (lower body and upper body), twice a week, 8 weeks, home Improvement on fatigue and sleep
Standard care
Wiskemann et al. (2016) 5 Fatigue and QoL Exercise 75 75 Exercise training, 15–45 minutes, 3 times a week, 12 weeks, hospital Improvement on fatigue and QoL
Standard care
Kako et al. (2018) 3 Dyspnea Fan therapy 20 20 Fan therapy, 5 minutes to the region which innervates the second and third branch of trigeminal nerve, every time patient experiences dyspnea, hospital Improvement on dyspnea
Fan therapy, 5 minutes to the legs up to thighs, every time patient experiences dyspnea, hospital
Pilegaard et al. (2018) 3 Daily activity level Occupational therapy 121 121 Occupational therapy, 1–3 visits each for 60–120 minutes sessions, 12 weeks, home No improvement
Standard care
Franciosi et al. (2019) 3 QoL, depression and anxiety Patient education 142 139 Consultation and follow-up, 45–60 minutes for initial visit and 20–40 minutes for following visits, 24 weeks, hospital Improvement on QoL, no improvement on depression
Standard care
Epstein et al. (2016) 5 QoL Patient education 188 195 Patient education, 60 minutes, 6 months, hospital Improvement on QoL
Standard care
do Carmo et al. (2017) 4 Depression Patient education 19 22 CBT, five weekly individual sessions, 90 days, hospital No improvement on depression
Early palliative care No improvement on depression
19 Standard care
Sikorskii et al. (2020) 4 Pain and QoL Reflexology 102 107 Reflexology, 30-minute (15 minutes for one foot) session for at least once a week, four consecutive weeks, home Improvement on pain
Standard care
Kocatepe et al. (2021) 5 Dyspnea Fan therapy 47 49 Fan therapy, 15 cm away from face for 5 minutes three times a day, 14 days, hospital Improvement on dyspnea
Standard care
Wong et al. (2017) 3 Dyspnea Fan therapy 15 15 Fan therapy, 5 minutes, research duration was not specified, hospital Improvement on dyspnea
Standard care
Open in a new tab

Note: QoL = quality of life; CBT = cognitive behavioral therapy; GET = graded exercise therapy; REST = rapid, easy, strength training.

Discussion

Fatigue is a significant problem, and it affects 62–85% of the cancer patients. Fatigue prevents patients from doing their daily activities, getting their treatments and drops their QoL. Descriptive studies show that cancer patients from the time they start their treatments to their death continues to experience fatigue (Wang et al., 2014). Available evidence shows that fatigue severity is also connected with increased mortality rate as well (Cheng & Lee, 2011). European Society for Medical Oncology (ESMO) guidelines suggest that moderate-intensity resistance training and home-based trainings are both effective on the management of fatigue; it is also stated in the guideline that when planning training to the patients, cachectic patients should be excluded because of their susceptibility to physical trauma (Fabi et al., 2020). Meta-analysis of Kessels et al. in 2018 also suggests that an aerobic exercise with high adherence levels is the most effective type of exercise for managing fatigue.

Included studies in this systematic review suggest that resistance-based exercise training for 12 weeks, CBT for 8 weeks, and home-based endurance training for 12 weeks were all effective management methods for fatigue. The evidence on usage of exercise and CBT on management of fatigue is not adequate. But it is shown that physical exercise doesn’t increases fatigue and still has other health benefits, so it is recommended to use physical exercise on patients’ with fatigue.

Quality of life is a multifactorial concept that gets effected from the patient’s symptoms, cultural beliefs, personal beliefs, and their perception of support. Psychological and physical symptoms of the cancer affect the patient’s QoL directly. Available evidence shows that pain, fatigue, dyspnea, anxiety, depression, and sleep deprivation are the symptoms that drops the QoL of the patients most significantly (Clark et al., 2013). Maintaining or improving QoL for cancer patients should be the first aim of the palliative care for the advanced and metastatic cancer patients. Since QoL gets affected from multiple factors, there is no definitive way for management. Alleviating patient’s symptoms, providing psychological and spiritual support, patient education, and implementing the patient participation in their treatment may help to increase the patient’s QoL.

Included studies in this systematic review suggest that both patient education and exercise are effective ways for improving patient’s QoL, while reflexology is not. Physical exercise known to alleviate dyspnea symptoms and patient education is known to have an effect on general symptom burden on cancer patients. Reflexology is generally used for pain management with the moderate effect, alleviating pain may improve a patient’s QoL but more high quality studies should be done to confirm this on advanced and metastatic cancer patients. It is recommended to use patient education and exercise for improving QoL of the patients, since reflexology doesn’t have a known adverse effect on patient’s if reflexology suits patient’s cultural and personal beliefs it might be beneficial to use it as well.

Sleep is essential for the continuity of life. Sleep deprivation is one of the most challenging symptom of cancer patients. Prevalence of sleep disorders between cancer patients is 24–95% (Mercadante et al., 2017). Sleep disorders can have different types such as not being able to fall asleep, waking earlier than normal, not feeling rested when waking up or not being able to continue the sleep. While psychological symptoms might trigger sleep disorders, sleep disorders themselves can also trigger physical symptoms such as fatigue and pain. Both ESMO and American Society of Clinical Oncology (ASCO) guidelines suggest that acupuncture and cognitive behavioral therapy are effective ways of managing sleep disorders (Mao et al., 2018). Meta-analysis done by Suh et al. in 2021 including 1318 patients founded that mindfulness-based stress reduction program for 8 weeks is effective for managing sleep disorders.

Included study in this systematic review by Cheville et al. in 2013 founded that physical exercise for 12 weeks is effective for management of sleep disorders. Physical activity can increase dopamine, serotonin, and norepinephrine levels in the brain which may help patients to sleep easier. For advanced and metastatic cancer patients, physical exercise might not be an option because of their symptom burden and physical condition. It is recommended that if the patient is available, physical exercise is an effective way to manage sleep disorders.

Dyspnea or shortness of breath is a complex and subjective symptom that can be very distressing for both the patient and his or her relatives. Along with pain, it is one of the most common symptoms in patients with advanced and metastatic cancer. Both the intensity and frequency of dyspnea typically increase with progression of disease prognosis (Damani et al., 2018). In the current literature, there are numerous nonpharmacological methods for the treatment of dyspnea. However, the most accessible and easy-to-use method with the highest level of evidence is fan therapy. Both the ESMO and ASCO guidelines recommend fan therapy as a treatment modality for dyspnea. While the ASCO guideline doesn’t specify how long or how far the fan should be used, it does suggest that almost any air movement in the face is useful for rapid relief of dyspnea. In contrast, the ESMO guideline clearly recommends the use of a fan for 5 minutes, but again doesn’t specify the distance (Hui et al., 2020, 2021) The meta-analysis performed by Yu et al. in 2019, involving 198 adults, states that application of the fan to the branches of the second and third branches of the trigeminal nerve for a duration of 5 minutes from a distance of 15–40 cm provides rapid and effective relief of dyspnea (Yu et al., 2019). Similarly, Kako et al.’s (2019) meta-analysis of 70 end-stage cancer patients showed that a 5-minute fan treatment directed at the patient’s face had a significant positive effect compared with no intervention or placebo (Kako et al., 2020).

Three included studies in this systematic review have founded that fan therapy was effective on the management of dyspnea for advanced and metastatic cancer patients. Five minutes of fan therapy from 15 to 40 cm of length targeting the second and third branch of trigeminal nerve is found to be most effective method. Because dyspnea is much more difficult to manage as death approaches and is highly responsive to psychological aspects of patients, it is recommended that nonpharmacologic methods be used in combination with pharmacologic methods to manage dyspnea. Fan therapy is an inexpensive, easy-to-use, and effective method of managing short-term dyspnea.

Depression can be hard to identify and manage on advanced cancer patients, because of cancer symptoms masking symptoms of depression such as fatigue, loss of appetite, and sleep disorders. Depression prevalence is 15–29% among cancer patients. Even though the prevalence seems low, it is four times higher than normal population (Irwin, 2013). Depression among cancer patients also known to be related to higher mortality rates and lower treatment adherence (Krebber et al., 2014). The meta-analysis done by Lopez et al. in 2019 with 3441 patients and it was found that cognitive behavioral therapy was effective on management of depression among patients (López-López et al., 2019).

In this systematic review, one study assessed CBT and one study assessed patient education on depression for advanced and metastatic cancer patients. Both CBT and patient education were not found effective in the management of depression for advanced and metastatic cancer patients. Since there is not enough evidence to draw definitive conclusions and there are evidence showing that CBT is effective for managing depression among cancer patients. It is recommended that CBT can be used to manage depression for patients with advanced and metastatic cancer.

Pain is the most common symptom in advanced and metastatic cancer patients (Bouhassira et al., 2017; Haenen et al., 2022; van den Beuken et al., 2016). Pain itself is a symptom that significantly lowers patients’ QoL, but research shows that pain is also associated with increased mortality and poor prognosis (Fizazi et al., 2015; Smith et al., 2014; Zylla et al., 2017). Despite all this evidence and guidelines, the literature also shows that pain is not appropriately managed in most patients (Cagle et al., 2015; Knaul et al., 2018; Kwon, 2014). Pain is a symptom that can be influenced by past experiences, cultural beliefs, age, gender, and many other factors. This may explain why pain management is difficult and underperformed in many palliative care clinics around the world (Sholjakova et al., 2018). Meta-analysis done by Lee et al. in 2015 including 559 participants founded that massage was effective in management of pain for advanced and metastatic cancer patients except patients with bone metastasis (Lee et al., 2015). ASCO guideline suggests music therapy, Transcutaneous Electrical Nerve Stimulation (TENS), massage, reflexology, acupuncture, and aromatherapy are effective methods for managing pain on advanced cancer patients (Mao et al., 2022).

In this systematic review, one study assessed the efficacy of reflexology for managing pain among advanced cancer patients. It was found that 15 minutes of reflexology for each foot, at least once a week for four consecutive weeks was effective in managing pain for advanced and metastatic cancer patients. Even though the amount of evidence is not enough, it is recommended to use reflexology as a method for managing cancer pain among advanced and metastatic cancer patients. Since reflexology doesn’t have known any adverse effects and it has been found to useful for managing pain for nonadvanced cancer.

Conclusion and Recommendations

This systematic review revealed that, although the studies currently in the literature are valuable, they either lack a homogeneous group of advanced and metastatic cancer patients or include pharmacological treatment of symptoms. However, the number of studies done regarding the advanced and metastatic cancer patients and their symptom management through nonpharmacological methods are low, which makes it difficult to draw decisive conclusions.

Therefore, more high-quality studies should be done regarding the symptom management through nonpharmacological methods.

Funding Statement

The authors declared that this study has received no financial support.

Footnotes

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – G.C., B.A.; Design – G.C., B.A.; Supervision – G.C.; Resources – B.A.; Materials – B.A.; Data Collection and/or Processing – G.C., B.A.; Analysis and/or Interpretation – G.C., B.A.; Literature Search – G.C.; Writing Manuscript – B.A.; Critical Review – G.C.

Declaration of Interests: The authors have no conflict of interest to declare.

References

  1. Armstrong M., Kupeli N., Flemming K., Stone P., Wilkinson S., & Candy B. (2020). Complementary therapy in palliative care: A synthesis of qualitative and quantitative systematic reviews. Palliative Medicine, 34(10), 1332–1339. ( 10.1177/0269216320942450) [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bouhassira D., Luporsi E., & Krakowski I. (2017). Prevalence and incidence of chronic pain with or without neuropathic characteristics in patients with cancer. Pain, 158(6), 1118–1125. ( 10.1097/j.pain.0000000000000895) [DOI] [PubMed] [Google Scholar]
  3. Bruera E., Kuehn N., Miller M. J., Selmser P., & Macmillan K. (1991). The Edmonton Symptom Assessment System (ESAS): A simple method for the assessment of palliative care patients. Journal of Palliative Care, 7(2), 6–9. ( 10.1177/082585979100700202) [DOI] [PubMed] [Google Scholar]
  4. Cagle J. G., Zimmerman S., Cohen L. W., Porter L. S., Hanson L. C., & Reed D. (2015). EMPOWER: An intervention to address barriers to pain management in hospice. Journal of Pain and Symptom Management, 49(1), 1–12. ( 10.1016/j.jpainsymman.2014.05.007) [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Chan K. S. (2018). Palliative care: The need of the modern era. Hong Kong Medical Journal, 24(4), 391–399. ( 10.12809/hkmj187310) [DOI] [PubMed] [Google Scholar]
  6. Cheng K. K., & Lee D. T. (2011). Effects of pain, fatigue, insomnia, and mood disturbance on functional status and quality of life of elderly patients with cancer. Critical Reviews in Oncology/Hematology, 78(2), 127–137. ( 10.1016/J.CRITREVONC.2010.03.002) [DOI] [PubMed] [Google Scholar]
  7. Cheville A. L., Kollasch J., Vandenberg J., Shen T., Grothey A., Gamble G., & Basford J. R. (2013). A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung and colorectal cancer: A randomized controlled trial. Journal of Pain and Symptom Management, 45(5), 811–821. ( 10.1016/J.JPAINSYMMAN.2012.05.006) [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Clark M. M., Rummans T. A., Atherton P. J., Cheville A. L., Johnson M. E., Frost M. H., Miller J. J., Sloan J. A., Graszer K. M., Haas J. G., Hanson J. M., Garces Y. I., Piderman K. M., Lapid M. I., Netzel P. J., Richardson J. W., & Brown P. D. (2013). Randomized controlled trial of maintaining quality of life during radiation therapy for advanced cancer. Cancer, 119(4), 880–887. ( 10.1002/CNCR.27776) [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Damani A., Ghoshal A., Salins N., Deodhar J., & Muckaden M. (2018). Prevalence and intensity of dyspnea in advanced cancer and its impact on quality of life. Indian Journal of Palliative Care, 24(1), 44–50. ( 10.4103/IJPC.IJPC_114_17) [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Deandrea S., Corli O., Consonni D., Villani W., Greco M. T., & Apolone G. (2014). Prevalence of breakthrough cancer pain: A systematic review and a pooled analysis of published literature. Journal of Pain and Symptom Management, 47(1), 57–76. ( 10.1016/J.JPAINSYMMAN.2013.02.015) [DOI] [PubMed] [Google Scholar]
  11. do Carmo T. M., Paiva B. S. R., de Oliveira C. Z., Nascimento M. S. A., & Paiva C. E. (2017). The feasibility and benefit of a brief psychosocial intervention in addition to early palliative care in patients with advanced cancer to reduce depressive symptoms: A pilot randomized controlled clinical trial. BMC Cancer, 17(1), 564. ( 10.1186/s12885-017-3560-6) [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. ElMokhallalati Y., Bradley S. H., Chapman E., Ziegler L., Murtagh F. E., Johnson M. J., & Bennett M. I. (2020). Identification of patients with potential palliative care needs: A systematic review of screening tools in primary care. Palliative Medicine, 34(8), 989–1005. ( 10.1177/0269216320929552) [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Epstein R. M., Duberstein P. R., Fenton J. J., Fiscella K., Hoerger M., Tancredi D. J., Xing G., Gramling R., Mohile S., Franks P., Kaesberg P., Plumb S., Cipri C. S., Street R. L., Shields C. G., Back A. L., Butow P., Walczak A., Tattersall M., … Kravitz R. L. (2016). Effect of a patient-centered communication intervention on oncologist-patient communication, quality of life, and health care utilization in advanced cancer: The VOICE randomized clinical trial. JAMA Oncology, 3(1), 92–100. ( 10.1001/JAMAONCOL.2016.4373) [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Fabi A., Bhargava R., Fatigoni S., Guglielmo M., Horneber M., Roila F., Weis J., Jordan K., Ripamonti C. I., & ESMO Guidelines Committee (2020). Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment. Annals of Oncology, 31(6), 713–723. ( 10.1016/J.ANNONC.2020.02.016) [DOI] [PubMed] [Google Scholar]
  15. Fadol A. P., Patel A., Shelton V., Krause K. J., Bruera E., & Palaskas N. L. (2021). Palliative care referral criteria and outcomes in cancer and heart failure: A systematic review of literature. Cardio-Oncology, 7(1), 32. ( 10.1186/s40959-021-00117-8) [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Ferrell B. R., Temel J. S., Temin S., Alesi E. R., Balboni T. A., Basch E. M., Firn J. I., Paice J. A., Peppercorn J. M., Phillips T., Stovall E. L., Zimmermann C., & Smith T. J. (2017). Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. Journal of Clinical Oncology, 35(1), 96–112. ( 10.1200/JCO.2016.70.1474) [DOI] [PubMed] [Google Scholar]
  17. Finucane A. M., Swenson C., MacArtney J. I., Perry R., Lamberton H., Hetherington L., Graham-Wisener L., Murray S. A., & Carduff E. (2021). What makes palliative care needs “complex”? A multisite sequential explanatory mixed methods study of patients referred for specialist palliative care. BMC Palliative Care, 20(1), 18. ( 10.1186/s12904-020-00700-3) [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Fizazi K., Massard C., Smith M., Rader M., Brown J., Milecki P., Shore N., Oudard S., Karsh L., Carducci M., Damião R., Wang H., Ying W., & Goessl C. (2015). Bone-related parameters are the main prognostic factors for overall survival in men with bone metastases from castration-resistant prostate cancer. European Urology, 68(1), 42–50. ( 10.1016/j.eururo.2014.10.001) [DOI] [PubMed] [Google Scholar]
  19. Franciosi V., Maglietta G., Degli Esposti C., Caruso G., Cavanna L., Bertè R., Bacchini G., Bocchi L., Piva E., Monfredo M., Scafuri V., Di Cesare P., Melotti B., Sequino M., Rimanti A., Binovi C., Ghisoni F., & Caminiti C. (2019). Early palliative care and quality of life of advanced cancer patients-a multicenter randomized clinical trial. Annals of Palliative Medicine, 8(4), 381–389. ( 10.21037/APM.2019.02.07) [DOI] [PubMed] [Google Scholar]
  20. Haenen V., Evenepoel M., de Baerdemaecker T., Meeus M., Devoogdt N., Morlion B., Dams L., van Dijck S., van der Gucht E., de Vrieze T., Vyvere vande T. V., & de Groef A. (2022). Pain prevalence and characteristics in survivors of solid cancers: A systematic review and meta-analysis. Supportive Care in Cancer, 31(1), 85. ( 10.1007/s00520-022-07491-8) [DOI] [PubMed] [Google Scholar]
  21. Hausner D., Tricou C., Mathews J., Wadhwa D., Pope A., Swami N., Hannon B., Rodin G., Krzyzanowska M. K., Le L. W., & Zimmermann C. (2021). Timing of palliative care referral before and after evidence from trials supporting early palliative care. Oncologist, 26(4), 332–340. ( 10.1002/ONCO.13625) [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Higginson I. J. (2016). Research challenges in palliative and end of life care. BMJ Supportive and Palliative Care, 6(1), 2–4. ( 10.1136/bmjspcare-2015-001091) [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hui D., Bohlke K., Bao T., Campbell T. C., Coyne P. J., Currow D. C., Gupta A., Leiser A. L., Mori M., Nava S., Reinke L. F., Roeland E. J., Seigel C., Walsh D., & Campbell M. L. (2021). Management of dyspnea in advanced cancer: ASCO Guideline. Journal of Clinical Oncology, 39(12), 1389–1411. ( 10.1200/JCO.20.03465) [DOI] [PubMed] [Google Scholar]
  24. Hui D., & Bruera E. (2017). The Edmonton symptom assessment system 25 years later: Past, present, and future developments. Journal of Pain and Symptom Management, 53(3), 630–643. ( 10.1016/j.jpainsymman.2016.10.370) [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Hui D., Maddocks M., Johnson M. J., Ekström M., Simon S. T., Ogliari A. C., Booth S., Ripamonti C. I., & ESMO Guidelines Committee . (2020). Management of breathlessness in patients with cancer: ESMO Clinical Practice Guidelines†. ESMO Open, 5(6), e001038. ( 10.1136/ESMOOPEN-2020-001038) [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Irwin M. R. (2013). Depression and insomnia in cancer: Prevalence, risk factors, and effects on cancer outcomes. Current Psychiatry Reports, 15(11), 404. ( 10.1007/s11920-013-0404-1) [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Isenberg S. R., Bonares M., Kurahashi A. M., Algu K., & Mahtani R. (2022). Race and birth country are associated with discharge location from hospital: A retrospective cohort study of demographic differences for patients receiving inpatient palliative care. EClinicalmedicine, 45, 101303. ( 10.1016/J.ECLINM.2022.101303) [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Kako J., Kobayashi M., Oosono Y., Kajiwara K., & Miyashita M. (2020). Immediate effect of fan therapy in terminal cancer with dyspnea at rest: A meta-analysis. American Journal of Hospice and Palliative Care, 37(4), 294–299. ( 10.1177/1049909119873626) [DOI] [PubMed] [Google Scholar]
  29. Kako J., Morita T., Yamaguchi T., Kobayashi M., Sekimoto A., Kinoshita H., Ogawa A., Zenda S., Uchitomi Y., Inoguchi H., & Matsushima E. (2018). Fan therapy is effective in relieving dyspnea in patients with terminally ill cancer: A parallel-arm, randomized controlled trial. Journal of Pain and Symptom Management, 56(4), 493–500. ( 10.1016/j.jpainsymman.2018.07.001) [DOI] [PubMed] [Google Scholar]
  30. Kennedy R., Abdullah N., Bhadra R., Bonsu N. O., Fayezizadeh M., & Ickes H. (2019). Barriers to effective use of palliative care services in the acute care setting with emphasis on terminal noncancer diseases. Indian Journal of Palliative Care, 25(2), 203–209. ( 10.4103/IJPC.IJPC_201_18) [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Knaul F. M., Bhadelia A., Rodriguez N. M., Arreola-Ornelas H., & Zimmermann C. (2018). The Lancet Commission on Palliative Care and Pain Relief—findings, recommendations, and future directions. Lancet Global Health. The Lancet Commission on Palliative Care and Pain Relief, 6, S5–S6. ( 10.1016/S2214-109X(18)30082-2) [DOI] [Google Scholar]
  32. Kocatepe V., Can G., & Oruç Ö. (2021). Lung cancer-related dyspnea: The effects of a handheld fan on management of symptoms. Clinical Journal of Oncology Nursing, 25(6), 655–661. ( 10.1188/21.CJON.655-661) [DOI] [PubMed] [Google Scholar]
  33. Krebber A. M. H., Buffart L. M., Kleijn G., Riepma I. C., Bree de R., Leemans C. R., Becker A., Brug J., Straten van A., Cuijpers P., & Verdonck-de Leeuw I. M. V. (2014). Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psycho-Oncology, 23(2), 121–130. ( 10.1002/PON.3409) [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Kwon J. H. (2014). Overcoming barriers in cancer pain management. Journal of Clinical Oncology, 32(16), 1727–1733. ( 10.1200/JCO.2013.52.4827) [DOI] [PubMed] [Google Scholar]
  35. Lee S. H., Kim J. Y., Yeo S., Kim S. H., & Lim S. (2015). Meta-analysis of massage therapy on cancer pain. Integrative Cancer Therapies, 14(4), 297–304. ( 10.1177/1534735415572885) [DOI] [PubMed] [Google Scholar]
  36. Lin Y., Long-Sutehall T., & Myall M. (2023). The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members’ experiences. Intensive and Critical Care Nursing, 76, 103399. ( 10.1016/j.iccn.2023.103399) [DOI] [PubMed] [Google Scholar]
  37. López-López J. A., Davies S. R., Caldwell D. M., Churchill R., Peters T. J., Tallon D., Dawson S., Wu Q., Li J., Taylor A., Lewis G., Kessler D. S., Wiles N., & Welton N. J. (2019). The process and delivery of CBT for depression in adults: A systematic review and network meta-analysis. Psychological Medicine, 49(12), 1937–1947. ( 10.1017/S003329171900120X) [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Mao J. J., Ismaila N., Bao T., Barton D., Ben-Arye E., Garland E. L., Greenlee H., Leblanc T., Lee R. T., Lopez A. M., Loprinzi C., Lyman G. H., MacLeod J., Master V. A., Ramchandran K., Wagner L. I., Walker E. M., Bruner D. W., Witt C. M., & Bruera E. (2022). Integrative medicine for pain management in oncology: Society for Integrative Oncology-ASCO Guideline. Journal of Clinical Oncology, 40(34), 3998–4024. ( 10.1200/JCO.22.01357) [DOI] [PubMed] [Google Scholar]
  39. Mao J. J., Xie S., Duhamel K., Bao T., Kantoff P. W., Li Q. S., Barg F., Song S., Gehrman P., & Garland S. N. (2018). The effect of acupuncture versus cognitive behavior therapy on insomnia in cancer survivors: A randomized clinical trial. Journal of Clinical Oncology, 36(15_suppl), 10001–10001. ( 10.1200/JCO.2018.36.15_suppl.10001) [DOI] [Google Scholar]
  40. Melnyk B. M., & Overholt E. F. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed). Wolters Kluver Health, Lippincott Williams & Willkins. [Google Scholar]
  41. Mercadante S., Adile C., Ferrera P., Masedu F., Valenti M., & Aielli F. (2017). Sleep disturbances in advanced cancer patients admitted to a supportive/palliative care unit. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 25(4), 1301–1306. ( 10.1007/S00520-016-3524-4) [DOI] [PubMed] [Google Scholar]
  42. Moher D., Liberati A., Tetzlaff J., Altman D. G., & PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. Annals of Internal Medicine, 151(4), 264. ( 10.7326/0003-4819-151-4-200908180-00135) [DOI] [PubMed] [Google Scholar]
  43. Mohsina S., Gurushankari B., Niranjan R., Sureshkumar S., Sreenath G. S., & Kate V. (2022). Assessment of the quality of randomized controlled trials in surgery using Jadad score: Where do we stand? Journal of Postgraduate Medicine, 68(4), 207–212. ( 10.4103/jpgm.JPGM_104_21) [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Oechsle K., Goerth K., Bokemeyer C., & Mehnert A. (2013). Symptom burden in palliative care patients: Perspectives of patients, their family caregivers, and their attending physicians. Supportive Care in Cancer, 21(7), 1955–1962. ( 10.1007/S00520-013-1747-1) [DOI] [PubMed] [Google Scholar]
  45. Oechsle K., Wais M. C., Vehling S., Bokemeyer C., & Mehnert A. (2014). Relationship between symptom burden, distress, and sense of dignity in terminally ill cancer patients. Journal of Pain and Symptom Management, 48(3), 313–321. ( 10.1016/J.JPAINSYMMAN.2013.10.022) [DOI] [PubMed] [Google Scholar]
  46. Pilegaard M. S., la Cour K., Gregersen Oestergaard L., Johnsen A. T., Lindahl-Jacobsen L., Højris I., Brandt Å. (2018). The ‘Cancer Home-Life Intervention’: A randomised controlled trial evaluating the efficacy of an occupational therapy-based intervention in people with advanced cancer. Palliative medicine, 32(4), 744–756. 10.1177/0269216317747199 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Poort H., Peters M. E. W. J., van der Graaf W. T. A., Nieuwkerk P. T., van de Wouw A. J., Nijhuis-van der Sanden M. W. G., Bleijenberg G., Verhagen C. A. H. H. V. M., & Knoop H. (2020) Cognitive behavioral therapy or graded exercise therapy compared with usual care for severe fatigue in patients with advanced cancer during treatment: A randomized controlled trial. Annals of Oncology, 31(1), 115–122. ( 10.1016/j.annonc.2019.09.002) [DOI] [PubMed] [Google Scholar]
  48. Sholjakova M., Durnev V., Kartalov A., & Kuzmanovska B. (2018). Pain relief as an integral part of the palliative care. Open Access Macedonian Journal of Medical Sciences, 6(4), 739–741. ( 10.3889/oamjms.2018.163) [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Sikorskii A., Niyogi P. G., Victorson D., Tamkus D., & Wyatt G. (2020). Symptom response analysis of a randomized controlled trial of reflexology for symptom management among women with advanced breast cancer. Supportive Care in Cancer, 28(3), 1395–1404. ( 10.1007/S00520-019-04959-Y) [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Smith D., Wilkie R., Uthman O., Jordan J. L., & McBeth J. (2014). Chronic pain and mortality: A systematic review. PLoS One, 9(6), e99048. ( 10.1371/JOURNAL.PONE.0099048) [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Suh H. W., Jeong H. Y., Hong S., Kim J. W., Yoon S. W., Lee J. Y., Chung S. Y. (2021). The mindfulness-based stress reduction program for improving sleep quality in cancer survivors: A systematic review and meta-analysis. Complementary Therapies in Medicine, 57, 102667. [DOI] [PubMed] [Google Scholar]
  52. Süren M., Doğru S., Önder Y., Yıldız Çeltek N., Okan İ., Çıtıl R., Karaman S., & Başol N. (2015). The evaluation of the symptom clusters in patients with the diagnosis of terminal stage cancer. Agri, 27(1), 12–17. ( 10.5505/agri.2015.07752) [DOI] [PubMed] [Google Scholar]
  53. Uysal N. (2015). Symptoms in palliative care inpatient and ımpact of palliative care unit on symptom control. Ağrı, 104–110. ( 10.5505/agri.2015.26214) [DOI] [PubMed] [Google Scholar]
  54. van den Beuken-van Everdingen M. H. J., Hochstenbach L. M. J., Joosten E. A. J., Tjan-Heijnen V. C. G., & Janssen D. J. A. (2016). Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. Journal of Pain and Symptom Management, 51(6), 1070–1090.e9. ( 10.1016/j.jpainsymman.2015.12.340) [DOI] [PubMed] [Google Scholar]
  55. Wang X. S., Zhao F., Fisch M. J., O’Mara A. M., Cella D., Mendoza T. R., & Cleeland C. S. (2014). Prevalence and characteristics of moderate to severe fatigue: A multicenter study in cancer patients and survivors. Cancer, 120(3), 425–432. ( 10.1002/cncr.28434) [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Wickham R. J. (2020). Revisiting the physiology of nausea and vomiting—Challenging the paradigm. Supportive Care in Cancer, 28(1), 13–21. ( 10.1007/s00520-019-05012-8) [DOI] [PubMed] [Google Scholar]
  57. Wilson J. G., English D. P., Owyang C. G., Chimelski E. A., Grudzen C. R., Wong H.-N., & Aslakson R. A. (2020). End-of-life care, palliative care consultation, and palliative care referral in the emergency department: A systematic review. Journal of Pain and Symptom Management, 59(2), 372–383.e1. ( 10.1016/j.jpainsymman.2019.09.020) [DOI] [PubMed] [Google Scholar]
  58. Wiskemann J., Hummler S., Diepold C., Keil M., Abel U., Steindorf K., Beckhove P., Ulrich C. M., Steins M., & Thomas M. (2016). POSITIVE study: Physical exercise program in non-operable lung cancer patients undergoing palliative treatment. BMC Cancer, 16, 499. ( 10.1186/s12885-016-2561-1) [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Wong S. L., Leong S. M., Chan C. M., Kan S. P., & Cheng H. W. B. (2017). The effect of using an electric fan on dyspnea in Chinese patients with terminal cancer. American Journal of Hospice and Palliative Medicine, 34(1), 42–46. ( 10.1177/1049909115615127) [DOI] [PubMed] [Google Scholar]
  60. World Health Organization (2020). Palliative Care. https://www.who.int/news-room/fact-sheets/detail/palliative-care [Google Scholar]
  61. Yu S., Sun K., Xing X., Zhong Y., Yan X., Qiu W., & Yan M. (2019). Fan therapy for the relief of dyspnea in adults with advanced disease and terminal illness: A meta-analysis of randomized controlled trials. Journal of Palliative Medicine, 22(12), 1603–1609. ( 10.1089/JPM.2019.0140) [DOI] [PubMed] [Google Scholar]
  62. Zeng Y. S., Wang C., Ward K. E., & Hume A. L. (2018). Complementary and alternative medicine in hospice and palliative care: A systematic review. Journal of Pain and Symptom Management, 56(5), 781–794.e4. ( 10.1016/j.jpainsymman.2018.07.016) [DOI] [PubMed] [Google Scholar]
  63. Zylla D., Steele G., & Gupta P. (2017). A systematic review of the impact of pain on overall survival in patients with cancer. Supportive Care in Cancer, 25(5), 1687–1698. ( 10.1007/s00520-017-3614-y) [DOI] [PubMed] [Google Scholar]

Articles from Florence Nightingale Journal of Nursing are provided here courtesy of Istanbul University - Cerrahpasa

RESOURCES