Investigating the composition of Palliative Care Pathways for Patients with Malignant Pleural Effusion: A Scoping Review

Malignant pleural effusion (MPE) is a common and debilitating complication of advanced malignancy, marked by increasing breathlessness, pain, fatigue, and a significant decline in quality of life. The condition is linked to frequent healthcare visits, unexpected hospital stays, and a heavy burden of procedures, and it often happens when people don't have long to live. Even though MPE is well known as a palliative condition, most of the care still focusses on managing procedures. There is a lot of variation in how and when palliative care is added to the patient's journey. Palliative care can help meet the complicated physical, mental, and emotional needs of people with MPE and their families. Nonetheless, there exists ambiguity and inconsistency concerning composition of palliative care pathways for this demographic. Pathways differ among healthcare systems and settings regarding referral timing, professional roles, coordination among respiratory, oncology, and palliative care services, and access to community-based support. These variations may be influenced by numerous determinants, including organisational infrastructure, clinical decision-making practices, service availability, professional boundaries, patient characteristics, and health system pressures. This scoping review seeks to systematically delineate the current literature concerning palliative care pathways for patients with malignant pleural effusion (MPE). It will identify the principal elements of these pathways, assess the integration of palliative care within the management of MPE, and investigate the clinical, organisational, and contextual factors that influence pathway design and implementation. The review will give a full picture of how care pathways in MPE are currently used and thought about by examining information from quantitative, qualitative, and mixed-methods studies, as well as reports on policy and service levels. The results will show where pathway models agree and disagree, point out gaps in the evidence, and make it clear where palliative care integration may be slow, inconsistent, or not happening at all. This will help create a clearer picture of how palliative care is given in MPE and guide future research, service development, and policy efforts to make care for this group of patients more coordinated, fair, and focused on the person. Background and Rationale Malignant pleural effusion impacts around 15% of cancer patients, leading to worsening dyspnoea, chest pain, and diminished functional status (Clive et al., 2014). Management usually involves repeat procedures or indwelling pleural catheters, as well as coordination between oncology, respiratory, primary care, community nursing, and palliative care services. However, current evidence indicates substantial variability in care delivery, postponed palliative referrals, disjointed coordination, and elevated rates of emergency admissions. MPE is a problem for both clinicians and organisations. Patients frequently access healthcare systems via acute pathways, often without substantial anticipatory planning. A lot of oncology and respiratory guidelines say that palliative care should be started as soon as possible, but how this is done varies a lot. Even though more people around the world are paying attention to palliative integration, there is no combined evidence that shows what palliative care pathways in MPE look like or what causes differences in service delivery, patient experiences, or outcomes. Aims and Objectives To systematically review the composition, attributes, and determinants of palliative care pathways for adults with MPE across healthcare settings, aiming to uncover discrepancies in practice, deficiencies in provision, and prospects for earlier, integrated, and patient centered palliative care. Objectives: To identify the current palliative care pathways for patients with malignant pleural effusion, encompassing their structural elements, timing, referral points, and service delivery models across various healthcare settings. To investigate the integration of palliative care within MPE management pathways, focussing on referral timing, coordination among respiratory, oncology, and palliative services, and the equilibrium between interventional and supportive care. To explore the principal determinants affecting the design and execution of palliative care pathways for MPE, encompassing clinical, organisational, professional, and systemic factors. To chart the reported results and desired objectives of palliative care pathways in MPE, including symptom management, quality of life, hospital admission, continuity of care, and patient or carer experience, when available. Registration The protocols will be registered to promote transparency, reduce bias and duplication, enhance methodological rigour, and ensure accountability in the conduct and reporting of research. Adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines has been maintained. Key Definitions Palliative care pathway: A systematic series of care exchanges designed to alleviate symptoms, provide holistic support, and address emotional, psychological, and practical needs, together with advance care planning for MPE Composition: Elements that affect the organisation of pathways (e.g., clinical requirements, personnel, service frameworks, health disparities, resource accessibility) MPE: Accumulation of pleural fluid resulting from malignancy, leading to considerable clinical distress Eligibility Criteria (PICOS) Population (P): Adults (≥18 years) with malignant pleural effusion, including patients, informal carers, and healthcare professionals involved in their care across all healthcare settings Intervention / Exposure (I): Palliative care pathways, models of care, service delivery approaches, and integrated or coordinated palliative care within the management of malignant pleural effusion. Comparator (C): Not required. Where reported, comparators may include standard care versus integrated palliative care, early versus late palliative care referral, or differing service models. Outcomes (O) 1. What evidence exists regarding the structure and components of palliative care pathways for patients with malignant pleural effusion? Secondary Questions 2. What determinants influence the design and implementation of palliative care pathways for malignant pleural effusion across different healthcare settings? 3. How is palliative care integrated and timed within the clinical trajectory of patients with malignant pleural effusion? 4. What are the reported perspectives and experiences of patients, carers, and healthcare professionals regarding palliative care pathways for malignant pleural effusion? 5. What patient, carer, and health service outcomes are reported in relation to these pathways (e.g., symptom burden, quality of life, experience of care, hospital admissions, emergency attendances, and procedural burden)? Study Design (S): Quantitative, qualitative, and mixed-methods studies; scoping reviews; published from all years Exclusion Non-malignant effusions Paediatric populations (under 18 years of age) Papers not written in English Non peer reviewed papers Information Sources Database specific search strategies will be developed and applied to each information source. Searches will be conducted from January 2019 to the date of the final search. The search will be limited to English language publications due to resource constraints, with no geographical restrictions applied. Academic literature will be identified through systematic searches of the following electronic databases: PubMed, MEDLINE, EMBASE, CINAHL, Scopus, Web of Science Search Strategy A search strategy: ("malignant pleural effusion" OR "MPE" OR "pleural malignancy") AND ("palliative care" OR "supportive care" OR "end of life" OR "Palliative pathway" OR "care pathway" OR "integrated care" OR "service model" OR "care coordination") Study Selection Procedure All records identified through database and supplementary searches will be imported into Covidence for management and screening. Following the removal of duplicates, two independent reviewers will screen titles and abstracts against the predefined eligibility criteria. Studies deemed potentially relevant will undergo full text screening by two reviewers. Reasons for exclusion at the full text stage will be documented. Any disagreements at either screening stage will be resolved through discussion, where consensus cannot be reached, a third reviewer will arbitrate. The study selection process will be reported using a PRISMA flow diagram, detailing the number of records identified, screened, assessed for eligibility, and included in the review. Data Extraction Data will be extracted using a customised and piloted data extraction (charting) form developed specifically for this review. The form will be used to systematically capture key descriptive and analytical information from all included sources and will be managed using Covidence. Data extraction will be undertaken by two reviewers, with consistency checked on an initial sample of included studies. Any discrepancies will be resolved through discussion, with involvement of a third reviewer if required. The following data items will be extracted where reported: Authors, year, country, study design Population and setting Components of pathways (clinical, psychological, organisational) Determinants affecting pathways Service frameworks (community, hospital, integrated care) Outcomes (patient experience, quality of life, utilisation) Employed conceptual frameworks Principal findings and suggestions Data Synthesis As a scoping review, the synthesis will be both descriptive and narrative. Proposed synthesis methodologies: Frequency analysis of study attributes Conceptual mapping of pathway elements Thematic analys