An umbrella review was conducted in accordance with the methodology outlined in the JBI (Joanna Briggs Institute) Manual for Evidence Synthesis [16]. The protocol for this umbrella review was originally registered in PROSPERO (CRD42024539963). The PRIOR (Preferred Reporting Items for Overviews of Reviews) checklist used for reporting this umbrella review is provided in Multimedia Appendix 1.

In this study, the inclusion criteria were identified based on the principles of PICOS (Population, Intervention, Comparison, Outcomes, and Study Type) framework [17], which was applied as follows. First, population: palliative care stakeholders regardless of age and ethnicity, such as patients (diagnosis of advanced cancer or a chronic disease unresponsive to active treatment), family caregivers, and health care professionals. Second, intervention: DH-based interventions provide information, support, and therapy (emotional, decisional, behavioral, and neurocognitive) for physical or mental health issues through technological or digital platforms (eg, website, videoconferencing, app, SMS text messaging, email, computer, and telephone) [18]. Third, comparison: no restrictions were set with regard to the types of comparators. Reviews were also considered eligible if they compared an eligible DH-based intervention arm to no intervention, including waitlist, usual care, or a sham intervention. Fourth, outcomes: changes in health or care process outcomes during DH-based palliative care; any outcomes about the efficacy or effectiveness dimension of evidence. Fifth, study type: systematic reviews published in English or Chinese, with or without meta-analysis. Scoping reviews were excluded as they do not typically assess study quality or synthesize intervention effects, making them less suitable for evaluating the strength of evidence in an umbrella review.

The exclusion criteria were as follows: (1) reviews focusing solely on outcomes for health care professionals and (2) papers reporting individual studies or protocols for forthcoming reviews, reviews of interventions that were not explicit and DH-based palliative care approaches, reviews with incomplete or irrelevant data, and unavailable reviews were also excluded in this study. Gray literature was excluded as the umbrella review focused solely on reviews of peer-reviewed, original studies [19].

The PubMed, Web of Science, Embase, Cochrane Library, CNKI, Wangfang, and VIP databases were used to systematically search for published studies from their inception to April 2024. Before refining the search terms, an initial search of PubMed for English studies and CNKI for Chinese studies was conducted to identify relevant search terms within the title and abstract. Subsequently, a search strategy combining free-text words and MeSH (Medical Subject Headings) terms was developed initially for PubMed and then adapted for each of the other databases. Building upon this foundation, the final search terms were tailored to the individual databases using Boolean phrases and operators; the key concepts of “palliative care” and “DH” were captured in each database. Moreover, a snowball method was also used to search the reference lists of the selected studies for reading and reference for a broader literature review. The detailed search terms, strategy, and results for each database were presented in Multimedia Appendix 2.

The search results were first imported into EndNote software (EndNote V.X9.1; Clarivate). After removing duplicate records, one researcher (JG) uploaded the remaining citations from EndNote to the Covidence (Veritas Health Innovation Ltd) software. After that, 2 researchers (JG and FC) then independently screened the titles and abstracts within Covidence for relevance to the research questions. To be included, studies must meet the inclusion criteria. The remaining full-text papers were also independently assessed for eligibility by the same 2 researchers. Any disagreements at either the title or abstract or full-text screening stage were discussed and resolved through consensus or consultation with a third independent reviewer (YC).

Two researchers (JG and FC) extracted and entered the data independently using a predesigned standardized form in Excel (Microsoft Corp, 2022). Any discrepancies between the 2 researchers were resolved through discussion or the third reviewer. The following information from the included reviews were extracted and synthesized: general details of the reviews (ie, first author, publication year, aim, review design, country, years covered by review, the number of studies included in the review, participants, and type of DH intervention), categories of DH based services in palliative care, the effects of DH on palliative care related outcomes (ie, outcome measure and findings), and the quality appraisal methods used by review authors and the results for included studies.

Due to the heterogeneity of the included reviews, a narrative description accompanied by supportive tabulations of the results was adopted. Specifically, the role of DH will be assessed by categorizing the reported outcomes and tabulating data, indicating whether the effects of the intervention are positive, negative, or not statistically significant. To identify and classify barriers to the use of DH-based services, we applied an inductive content analysis following the methodological guidance of Elo and Kyngäs [20]. Content-specific terms and phrases extracted from the reviews served as the unit of analysis. Two reviewers independently coded the data, and categories were iteratively refined through discussion until consensus was reached.

The JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses was used to assess the quality of each review paper [21]. The checklist includes 11 structured questions, and reviews were considered to be of high quality when all included studies achieved at least 50% of the maximum possible score [19]. The assessment was conducted independently by 2 researchers (JG and YD); any discrepancies between the 2 researchers were resolved through discussion or the third reviewer.

Ethical approval is not necessary for the umbrella review.

In this study, a total of 7295 records were retrieved from 7 electronic databases. After removing 1677 duplicates, 5618 records were screened by titles and abstracts, of which 5536 were excluded. The full texts of the remaining 82 records were retrieved for eligibility assessment, and after the full-text screening, 57 studies were excluded. Finally, 25 studies were included in this umbrella review. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of study selection is shown in Figure 1.

The included reviews were published between 2012 and 2024, with most of them having been conducted in United Kingdom (n=7) [22-28] and United States (n=7) [29-35], and the remaining 11 were conducted in China (n=4) [14,15,36,37], Australia (n=1) [38], Norway (n=1) [39], Chile (n=1) [40], France (n=1) [41], Greece (n=1) [13], Denmark (n=1) [42], and Colombia (n=1) [43]. The reviews included studies using various experimental designs. Three reviews consisted entirely of randomized controlled trials [14,15,36]. Additionally, 4 systematic reviews [14,15,25,29] also performed meta-analyses combining randomized controlled trial results on variables relevant to this umbrella review. Most reviews encompassed a range of study populations, including patients, family caregivers, and health care professionals. Two reviews [15,33] focused exclusively on DH-based interventions for caregivers, while 2 specifically addressed pediatric palliative care [26,38]. More details are shown in Table 1.

Of the included reviews, the DH-based services in palliative care can be classified into the following 7 categories: communication and information exchange (asynchronous and synchronous), symptom management, psycho-social and spiritual support, advance care planning (ACP) and decision-making support, education and health literacy promotion, care coordination and reminders, and caregiver support. Among all these categories, DH-based communication and information exchange services were the most commonly used in palliative care, as reported in 21 reviews [13-15,22-30,32-38,40,42]. Additionally, 20 reviews [13-15,22,24-26,28-34,36,37,40-43] identified symptom management as the primary focus of DH-based interventions. Education and health literacy promotion were reported in 11 reviews [13,14,25,27-29,34-36,40,43], followed by care coordination and reminders in 9 reviews [14,24,27,29,31,32,38,41,43]. ACP and decision-making support were addressed in 7 reviews [14,15,25,31,34,36,37], psychosocial and spiritual support in 5 reviews [14,15,32,37,43], and caregiver support in 2 reviews [15,43].

The summary statistics of the effect of DH on palliative care-related outcomes are shown in Multimedia Appendix 3 [13-15,23-34,36-38,40-42].

A total of 6 reviews [14,23,25,33,36,41] reported the effects of DH-based palliative care on patient symptom management outcomes. However, these reviews presented inconsistent findings. A total of 5 reviews [23,25,33,36,41] reported positive effects of DH-based palliative care on patient symptom management, 1 study [14] that conducted a meta-analysis showed DH-based palliative care had no statistically significant effect on improving the symptoms of advanced patients. There was a lack of evidence on the effects of DH-based palliative care on patient symptom management outcomes.

A total of 8 reviews [14,15,29,32-34,36,38] reported the effects of DH-based palliative care on patient mood outcomes. Compared to usual care, some reviews reported that the DH-based palliative care can significantly reduce patients’ mood. However, 1 study [15] that conducted a meta-analysis showed DH-based palliative care had no statistically significant effect on reducing patients’ depression, but had a statistically significant effect on reducing anxiety. Additionally, 2 reviews [14,29] also conducted meta-analyses, reported that there was no difference between standard care and DH-based interventions in reducing the severity of anxiety and depression.

A total of 2 reviews [29,34] reported the effects of DH-based palliative care on patient distress outcomes. However, these reviews also presented inconsistent findings. Reviews conducted by Kamalumpundi et al [29] indicated that DH-based palliative care interventions did not show a significant improvement in reducing distress severity compared with standard care. Another review conducted by Ostherr et al [34] found that the information and communications technologies can significantly decrease symptom distress in the intervention arm. There was a lack of evidence on the effects of DH-based palliative care on patient distress outcomes.

A total of 10 reviews [14,15,25,26,32-34,36,38,40] reported the effects of DH-based palliative care on patient quality of life. Most of the reviews showed there was no significant difference in quality of life between the intervention group with DH-based palliative care and the control group with standard care. However, the reviews also indicated that negative impacts were rarely observed, although there was no significant difference between the control group and intervention group.

A total of 2 reviews [23,30] reported the effects of DH-based palliative care on patient psycho-social or emotional well-being. Both results of reviews reported that DH-based palliative care has a positive impact on patient psycho-social and emotional well-being.

A total of 3 reviews [15,33,36] reported the effects of DH-based palliative care on caregiver burden. The results of reviews reported that DH-based palliative care has a positive effect on caregiver burden.

A total of 3 [25,28,34] reviews reported the effects of DH-based palliative care on patient decision-making. However, the evidence was weak. One review [28] reported there was a statistically significant difference in developing ACP-related indicators between intervention groups and control groups. Other reviews [25,34] reported that the DH-based interventions potentially benefited ACP and could reduce decisional conflict.

A total of 4 reviews [25,31,40,42] reported the effects of DH-based palliative care on communication. The results of all 4 reviews showed that DH-based palliative care can facilitate communication between patients and health care professionals.

A total of 3 reviews [14,30,41] reported the effects of DH-based palliative care on patients’ or family caregivers’ self-efficacy or self-management efficacy. The results of all 3 reviews showed that DH-based palliative care can improve their self-efficacy or self-management efficacy.

A total of 2 reviews [26,33] reported the effects of DH-based palliative care on family empowerment. The results of both reviews showed that DH-based palliative care can improve family empowerment.

A total of 5 reviews [23,27,31,32,38] reported the effects of DH-based palliative care on hospital or intensive care unit (ICU) admission. Among them, 4 reviews [23,27,32,38] identified that patients who accessed DH-based interventions had a lower risk of hospital admission. One review [31] reported patients in the control group who received usual care had higher adjustment odds of ICU admission during the last 6 months and higher odds of death in the hospital or in the ICU. In addition to hospital or ICU admission, most reviews reported the positive effects of DH-based interventions in reducing emergency care use.

A total of 8 reviews [13,23,25,27,32,38,40,42] reported the effects of DH-based palliative care on costs. Most reviews [13,25,27,32,38,40] reported the positive effects of DH-based interventions on costs for patients, caregivers, or health care providers; several reviews identified that DH-based interventions can significantly cause a drop in hospital care costs [32,38].

A total of 13 reviews [23,24,26-28,32,33,36-38,40-42] reported the acceptability or feasibility of DH. Most reviews [23,24,27,32,36,40-42] showed that the user experiences were overwhelmingly positive, such as the high levels of user satisfaction reported among patients and family members participating in DH-based interventions. Several reviews also found that DH was well-accepted among health care staff [27,41,42].

A total of 8 reviews [22,30,35,37-39,42,43] reported barriers to using DH in palliative care settings. Six main categories, including technical challenges, organizational factors, ethical concerns, resource constraints, nonverbal communication, perceptions, and 14 generic categories describing barriers to the use of DH-based services were identified in this review (Figure 2).

Technical challenges, including insufficient technology literacy and knowledge (eg, lack of professional training or being overwhelmed), device use concerns (eg, software malfunctions, confidentiality, and individualization), and distrust in technology, limited the use of DH-based services. The successful use of DH-based service was also influenced by organizational factors, including a lack of leadership and encouragement from the management. Additionally, ethical concerns are also a barrier to the use of DH-based services, including privacy and security, and burnout among health care professionals. Furthermore, the use of DH-based services was not supported in palliative care settings, due to a lack of nonverbal communication and perceptions, nonverbal communication such as professionals’ acting (eg, lacking in human touch or nonverbal cues) and complicating goals of care conversations, perceptions including the readiness of patients and professionals (eg, lack of experience or unfamiliarity). Other barriers, including resource constraints, such as affordability, connectivity (eg, internet access), and reimbursement challenges, also hinder the use of DH-based services.

The quality appraisal methods used by the systematic review authors were presented in Multimedia Appendix 4 [13-15,22-43]. Most reviews used instruments from either the JBI or the Cochrane Collaboration, while 4 [23,24,37,39] used the Mixed Methods Appraisal Tool. Several authors also advised caution in interpreting results due to the variability in study quality. In this study, the results of critical appraisal of included systematic reviews were presented in Multimedia Appendix 5 [13-15,22-43]. The overall quality of the included reviews was moderate, and the high risk of bias was most often related to the critical appraisal, data extraction, and assessment of publication bias.

In 2016, a study [44] similar to ours investigated the use of telemedicine in palliative care. However, that study focused solely on the feasibility of telemedicine in this context and did not provide a detailed summary of the categories of DH-based services in palliative care, nor did it address the barriers and effects of DH applications in this field. To address the shortcomings of previous studies, this umbrella review systematically examined, appraised, and synthesized previous systematic reviews that specifically linked explicitly articulated DH-based interventions to palliative care services, and provided new, valuable insights for the continuous development and optimization of palliative care practices in the digital age.

In this review, we reported a total of 7 different DH-based services within palliative care settings, with the DH-based communication and information exchange services being the most widely used in this field. Communication and information exchange are an indispensable element in palliative care, and effective communication plays a crucial role in helping patients and their families understand the nature of the illness, the trajectory of the disease, and the available care options [45]. Clear, timely communication ensures that patients and their families are well-informed and can make educated decisions about the care they wish to receive [46]. Additionally, symptom management is also one of the crucial components of DH-based palliative care services. For most patients receiving palliative care, negative symptoms such as pain are commonly experienced. A longitudinal study funded by the National Institute on Aging identified that approximately 50% of these patients reported pain, and the rate tends to be higher among patients at home [47,48]. DH-based symptom management enables health care providers to track symptoms and vital signs from a distance, empowering patients and caregivers to record and manage symptoms proactively, contributing to a more comfortable experience [25,36]. Moreover, we also found that patient-centered education is one of the common services in DH-based palliative care. Education tailored to the specific needs of patients and their families not only enhances their understanding of the disease and care options but also fosters a sense of autonomy in managing symptoms and making decisions such as preferred place of death [49]. In the field of DH-based palliative care, digital platforms can serve as powerful tools for delivering personalized educational content, such as video tutorials, interactive modules, and real-time consultations with health care providers [25]. These resources can bridge the gap between clinical settings and home environments, ensuring continuity of care and reducing the burden on caregivers.

We synthesized evidence from 25 systematic reviews to evaluate 13 outcomes of DH-based interventions in palliative care. The overall role of DH-based interventions for palliative care was basically consistent, with all included studies reporting either significant improvements or noninferiority of DH-based interventions as compared to usual care. No reviews reported any adverse effects associated with DH-based interventions in palliative care settings. Some reviews reported that DH-based interventions were associated with significant reductions in caregiver burden [15,33,36], hospital or ICU admission [23,27,31,32,38], and costs [13,25,27,32,38,40], facilitates communication [25,31,40,42] and symptom management [23,25,33,36,41], improves self-efficacy [14,27,34] of patients and family caregivers, psycho-social or emotional well-being [23,30], and family empowerment [26,33]. For reduction in caregiver burden, a possible explanation for this result is that DH technologies can provide resources and tools for managing symptoms, educational materials, and establishing direct lines of communication between caregivers and health care professionals [50]. This support can alleviate the physical and emotional strain experienced by caregivers in managing the care of their loved ones, thereby improving their overall well-being. Additionally, DH technologies play a critical role in enabling the continuous monitoring of patient anthropometric and functional parameters [51]. These technologies, which include wearable devices, remote monitoring systems, and mobile health apps, allow health care providers to track vital signs, physical activity, and other health metrics in real-time. By enabling the early detection of health deterioration or complications, DH technologies facilitate timely interventions, potentially reducing the necessity for hospitalization or ICU admission [27]. A patient with advanced chronic heart failure may use a wearable device to monitor heart rate and fluid retention. Upon detection of any abnormalities, the health care team can intervene promptly, potentially preventing the need for an emergency hospital admission. This proactive approach not only improves patient care outcomes but also alleviates the strain on hospital resources and thereby cuts down on unnecessary health care expenses [31,32]. However, the review did not identify potential time savings associated with DH-based palliative care services due to a lack of sufficient evidence; future research could further explore the effects of this service on time costs. Moreover, DH tools such as continuing care service platforms often include educational resources and self-management features that empower patients and caregivers. By providing detailed information about the illness, treatment options, and symptom management strategies, these tools enhance the self-efficacy of both patients and their caregivers [14,41]. When individuals feel more knowledgeable and capable of managing their care, they may tend to experience better outcomes and higher satisfaction [14]. Furthermore, the results showed DH tools contribute to the psycho-social and emotional well-being of patients by offering accessible avenues for psychological support, including peer forums and tailored mental health resources. These features help alleviate feelings of anxiety, depression, and uncertainty [23,30]. Regular communication with health care providers and support networks through digital platforms further fosters a sense of connection and emotional safety, enhancing overall well-being [23,30]. At the same time, DH interventions promote family empowerment by facilitating shared decision-making and transparent communication. Features such as digital care planning and online family meetings enable family members to remain actively engaged in the care process, regardless of physical distance [14,30,41]. This collaborative model strengthens family cohesion and confidence in managing care needs, thereby enhancing the family’s sense of control, involvement, and preparedness throughout the palliative care journey. However, it needs to be acknowledged that current evidence on the effects of DH interventions on psycho-social and emotional well-being and family empowerment remains limited; more research is needed to confirm and expand upon these initial observations.

While identifying the potential benefits of DH-based palliative care services, this review also explored some of the barriers to using DH in palliative care settings. A frequently cited barrier in the included studies was technical challenges, including insufficient technology literacy and knowledge, and device use concerns, such as individualization. DH tools often require users to possess a certain level of familiarity with technology and digital interfaces. For health care providers, insufficient training in using DH tools can lead to suboptimal use, reduced confidence, and potential errors in patient care [22]. Similarly, patients and their families may struggle with the technical aspects of DH tools if they lack experience or support, which can hinder their ability to engage effectively with these technologies [37,39]. Additionally, DH technologies often need to be tailored to meet the specific needs and preferences of individual patients and their care plans. Most people who receive palliative care are older adults [52], and patients’ needs can be highly diverse and changeable; a one-size-fits-all approach may not be effective. Failure to adequately customize DH tools for individual patients may result in reduced efficacy and lower engagement, undermining the potential benefits of these technologies. Addressing these issues through targeted routine training and improved system reliability is essential for maximizing the role of DH technologies and ensuring their successful integration into palliative care practices. Moreover, resource constraints also hinder the use of DH-based services, particularly the lack of reliable internet access, a challenge that is especially prevalent in rural and remote areas due to limited infrastructure investment, lower population density, and the high costs associated with establishing and maintaining broadband networks in geographically isolated regions [22,43]. Future practitioners can collaborate with policy makers and technology providers to ensure affordable, reliable internet access in resource-limited communities. Emphasizing community engagement and scalable solutions can further help bridge the digital divide and enhance access to DH-based services in remote regions [53,54].

This umbrella review identifies several key barriers to the successful implementation and adoption of DH in palliative care, providing clear guidance for both clinical practice and future research (Textbox 1).

One major limitation is the heterogeneity among the studies included in the review. The reviewed studies varied in terms of DH-based interventions assessed, study designs, patient populations, and outcome measures. This diversity may complicate the synthesis of results and limit the ability to draw broad, uniform conclusions. Therefore, our recommendations and conclusions should be considered with due caution. Additionally, DH technologies are rapidly evolving, and the pace of technological advancement means that the evidence reviewed may quickly become outdated. New technologies and innovations can emerge, altering the landscape of DH in palliative care and potentially affecting the relevance of earlier findings.

This umbrella review synthesized evidence from existing systematic reviews to provide a comprehensive overview of the role of DH in palliative care. Among included reviews, DH was consistently reported to be either beneficial or noninferior compared with standard care, and no adverse effects were identified, indicating that DH is a safe and feasible mode of service delivery. To ensure successful implementation and long-term sustainability, a multifaceted strategy is needed that integrates technological enhancements and training, organizational commitment, ethical safeguards, infrastructure development, and equitable access. This work will support continued growth in the reach and effects of DH-based interventions to improve care outcomes for individuals receiving palliative care.