Purpose: Little is known about the use of palliative and hospice care and their impact on healthcare utilization near the end of life (EOL) in early-onset pancreatic cancer (EOPC).
Methods: Patients with EOPC (= 50 years) were identified using the institutional tumor registry for years 2011–2018, and demographic, clinical, and rates of referral to palliative and hospice services were obtained retrospectively. Predictors of healthcare utilization, defined as use of = 1 emergency department (ED) visit or hospitalization within 30 days of death, place of death (non-hospital vs. hospital), and time from last chemotherapy administration prior to death, were assessed using descriptive, univariable, and multivariable analyses including chi-square and logistic regression models.
Results: A total of 112 patients with EOPC with a median age of 46 years (range, 29–50) were studied. Forty-four percent were female, 28% were Black, and 45% had metastatic disease. Fifty-seven percent received palliative care at a median of 7.8 weeks (range 0–265) following diagnosis. The median time between last chemotherapy and death was 7.9 weeks (range 0–102). Seventy-four percent used hospice services prior to death for a median of 15 days (range 0–241). Rate of healthcare utilization at the EOL was 74% in the overall population. Black race and late use of chemotherapy were independently associated with increase in ED visits/hospitalization and hospital place of death.
Conclusions: Although we observed early referrals to palliative care among patients with newly diagnosed EOPC, short duration of hospice enrollment and rates of healthcare utilization prior to death were substantial.
De quoi et où meurent les Françaises et Français ? Quelle est l’offre sanitaire globale mais aussi plus spécifiquement de soins palliatifs aujourd’hui en France ? Quel est le profil des patients pris en charge dans les unités de soins palliatifs ? Quelle est la part des personnes âgées de 75 ans et plus dans les statistiques de mortalité ? Quelles sont leurs particularités ? Observe-t-on des différences géographiques concernant toutes ces données ?
Cette deuxième édition de l'Atlas national a vocation à répondre à ces multiples questions pour aider le lecteur à appréhender les enjeux et les réalités de l’accompagnement de la fin de vie et de la place des soins palliatifs en France aujourd’hui. Il rassemble des données démographiques, sanitaires qui sont analysées le plus finement possible pour mettre en lumière les spécificités départementales en termes d’offre sanitaire mais aussi de besoins des patients dans leurs trajectoires de fin de vie.
PURPOSE: End-of-life cancer care varies widely, and very few centers evaluate it systematically. Our objective was to assess indicators of the aggressiveness of end-of-life cancer care in clinical practice.
METHODS: An observational, longitudinal, and retrospective cohort study was conducted at a tertiary hospital. Eligible patients were at least 18 years old, had a solid tumor, were followed up by the Oncology Department, and had died because of cancer or associated complications during 2017. We used the criteria of Earle et al. (J Clin Oncol 21(6):1133-1138, 2003) to assess the aggressiveness of care. Multivariate logistic regression analyses were performed to characterize factors associated with aggressiveness of therapy.
RESULTS: The study population comprised 684 patients. Eighty-eight patients (12.9%) received anti-cancer treatment during the last 14 days of their lives, and 62 patients (9.1%) started a new treatment line in the last 30 days. During the last month of life, 102 patients (14.9%) visited the ER, 80 patients (11.7%) were hospitalized more than once, and 26 (3.8%) were admitted to the ICU. A total of 326 patients (47.7%) died in the acute care unit. A total of 417 patients (61.0%) were followed by the Palliative Care Unit, and in 54 cases (13.0%), this care started during the last 3 days of life.
CONCLUSIONS: The use of anti-cancer therapies and health care services in our clinical practice, except for the ICU, did not meet the Earle criteria for high-quality care. Concerning hospice care, more than half of the patients received hospice services before death, although in some cases, this care started close to the time of death.
Released in 2016, That Dragon, Cancer was created by Joel’s parents, indie game developer Ryan Green and his wife Amy, to tell his story interactively and thus honor his too-short life. Diagnosed at age 1 with an atypical teratoid rhabdoid tumor and given months to live, Joel lived with his disease for 4 years. Over the course of several vignettes, players progress through his diagnosis, treatment, and death using point-and-click–style mechanics and occasional game styles from other video games (platforming, racing, puzzle solving). Wavering between hyperrealism and fantasy, players experience Joel’s joy playing with a puppy and the horror of being unable to console him, the fantasy of imaginative play and the banality of a cross-country trip to participate in a clinical trial, and more. In short, the game sets out to encompass the fullness of Joel’s life.
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OBJECTIVES: To (a) compare palliative care needs of lung cancer patients on their final admission to community-based and inpatient palliative care services; and (b) explore whether and how these care needs affect their utilisation of different palliative care services in the last days of life.
METHODS: Descriptive study involving 17,816 lung cancer patients who received the last episode of palliative care from specialist services and died between 1 January 2013 and 31 December 2018.
RESULTS: Both groups of patients admitted to community-based and inpatient palliative care services generally experienced relatively low levels of symptom distress, but high levels of functional impairment and dependency. "Unstable" versus "stable" palliative care phase (Odds ratio = 11.66; 95% Confidence Interval: 9.55-14.24), poorer functional outcomes and severe levels of distress from many symptoms predicted greater likelihood of use of inpatient versus community-based palliative care.
CONCLUSIONS: Most inpatient palliative care admissions are not associated with high levels of symptom severity. To extend the period of home care and rate of home death for people with lung cancer, additional investment is required to improve their access to sufficiently skilled palliative care staff, multi-disciplinary teams and 24-hour home support in community settings.
CONTEXT: Little is known about receipt of specialty-level palliative care by people with hepatocellular carcinoma (HCC), or its impact on healthcare utilization.
OBJECTIVES: Identify patient characteristics associated with receipt of specialty-level palliative care among hospitalized HCC patients and measure association with time to readmission.
METHODS: We used logistic regression to examine relationships between receipt of inpatient palliative care consultation by HCC patients at an academic center (N=811, 2012-2016), and clinical and demographic covariates at index hospitalization. We used a survival analysis model accounting for competing risk of mortality to compare time to readmission among individuals who did or did not receive palliative care during the admission and performed a sensitivity analysis using kernel weights to account for selection bias.
RESULTS: Overall, 16% received inpatient palliative care consults. Those who received consults had worse laboratory values than those who did not. In a multivariable model, higher MELD-Na, receipt of sorafenib, and higher pain scores were significantly associated with increased odds of palliative care, while liver transplantation and admission to a surgical service were associated with lower odds. For time to readmission (2,076 hospitalizations for 811 individuals with 175 palliative care visits), the sub-hazard ratio for readmission for patients who received consults was 0.26 (95% Confidence Interval [CI] 0.18-0.38) and 0.35 (CI 0.24-0.52) with a kernel-weighted sample.
CONCLUSION: Inpatient palliative care consultation was received by individuals with more advanced disease, and was associated with lower readmission hazard. These findings support further research and the development of HCC-specific programs that increase access to specialty-level palliative care.
CONTEXT: Cancer prognosis data often comes from clinical trials which exclude patients with acute illness.
OBJECTIVES: For patients with Stage IV cancer and acute illness hospitalization, to 1) describe predictors of 60-day mortality, and 2) compare documented decision-making for survivors and decedents.
METHODS: Investigators studied a consecutive prospective cohort of patients with Stage IV cancer and acute illness hospitalization. Structured health record and obituary reviews provided data on 60-day mortality (outcome), demographics, health status, and treatment; logistic regression models identified mortality predictors.
RESULTS: 492 patients with Stage IV cancer and acute illness hospitalization had median age of 60.2 (51% female, 38% minority race/ethnicity); 156 (32%) died within 60 days and median survival for decedents was 28 days. Nutritional insufficiency (OR 1.83), serum albumin (OR 2.15 per 1.0 g/dL) and hospital days (OR 1.04) were associated with mortality; age, gender, race, cancer and acute illness type were not predictive. On admission 79% of patients had orders indicating Full Code. During 60-day follow-up 42% of patients discussed goals of care. Documented goals of care discussions were more common for decedents than survivors (70% vs 28%, p<0.001), as were orders for DNR / DNI (68% vs 24%, p<0.001), stopping cancer-directed therapy (29% vs 10%, p<0.001), specialty Palliative Care (79% vs 44%, p<0.001) and Hospice (68% vs 14%, p<0.001).
CONCLUSION: Acute illness hospitalization is a sentinel event in Stage IV cancer. Short-term mortality is high; nutritional decline increases risk. For patients with Stage IV cancer, acute illness hospitalization should trigger goals of care discussions.
OBJECTIVE: Patients with left ventricular assist devices (LVADs) need expert palliative care at the end of life. In the U.S., hospice may provide this care, but few patients enroll and information about hospice experience with LVAD-implanted patients is limited.
AIM: To describe hospice experience with LVAD-implanted patients.
METHODS: This is a retrospective descriptive study of all LVAD-implanted patients admitted to a hospice agency. Data were extracted from the electronic health record.
RESULTS: The 13 patients had a mean age of 63 years (range 20 to 89) and a mean LVAD duration of 32.5 months (range 8.2 to 70.0). Hospice diagnosis was heart failure in 10 patients and cancer in 3; all patients were multimorbid. Eight patients enrolled in hospice on one occasion, four had two enrollments, and one had five. All patients received services for <180 days, three for <7 days and four patients for >90 days. Just-in-time in-servicing was used to prepare hospice teams for challenging care needs, including bleeding, delirium, infections and mechanical failure. Of the nine patients who died while receiving hospice services, one enrolled with a plan to deactivate the LVAD immediately after hospice enrollment and six died following discontinuation of the LVAD or other life-sustaining therapy during the course of hospice care. Five deaths occurred in a hospice inpatient unit.
CONCLUSION: To provide specialist palliative care to LVAD-implanted patients, hospices must be prepared to manage complex and highly varied needs. To do this, hospices must have adequate staff support and access to acute care.
BACKGROUND: National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory.
OBJECTIVE: To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites.
METHODS: A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis.
RESULTS: Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity).
CONCLUSIONS: The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.
INTRODUCTION: Cancer prevalence (people alive on a certain date in a population who previously had a cancer diagnosis) is expected to increase in the United States and Europe due to improvements in survival and population aging. Examination of prevalence by phase of care allows us to identify subgroups of patients according to their care trajectories, thus allowing us to improve health care planning, resource allocation, and calculation of costs.
METHODS: A new method to estimate prevalence by phase of care using grouped data is illustrated. Prevalence is divided into 3 mutually exclusive phases: initial, continuing, and end-of-life. An application to US and Italian data is applied to prevalent cases diagnosed with colon-rectum, stomach, lung, or breast cancer.
RESULTS: The distribution of phase of care prevalence estimated by cancer type and sex and results from the two datasets are very similar. Most survivors are in the continuing phase; the end-of-life phase is larger for cancers with worse prognosis. All phases prevalence is generally higher in the Italian than in the US dataset, except for lung cancer in women, where prevalence proportion in the Italian dataset is 30% lower than in the United States.
DISCUSSION: Incidence, survival, and population age structure are the main determinants of prevalence and they can affect differences in all phases of prevalence, as well as in discrete phases. Incidence is the most influential determinant. Ours is the first study that compares prevalence by phase of care between two populations in Italy and the United States. Despite great differences in health care management in the two countries, we found extremely similar distribution of survivors by phase of care for most cancer sites under study.
CONTEXT: Cancer patients' comfort near the end of life is often undermined by unnecessary and burdensome treatments. There is a need for more research examining racial disparities in end-of-life care, especially in regions with a history of racial discrimination.
OBJECTIVES: To examine whether Black adults received more burdensome end-of-life care than White adults in a population-based data set of cancer decedents in Louisiana, a state with a history of slavery and long-standing racial disparities.
METHODS: This was a retrospective analysis of end-of-life care from the Research Action for Health Network (REACHnet), a regional PCORI-funded database. The sample consisted of 875 White and 415 Black patients with metastatic cancer who died in Louisiana from 2011-2017. We used logistic regression to examine whether race was associated with five indicators of burdensome care in the last 30 days of life: chemotherapy use, inpatient hospitalization, intensive care unit (ICU) admission, emergency department (ED) admission, and mechanical ventilation.
RESULTS: Most patients (85.0%) received at least one indicator of burdensome care: hospitalization (76.5 %), ICU admission (44.1%), chemotherapy (29.1%), mechanical ventilation (23.0%), ED admission (18.3%). Odds Ratios (ORs) indicated that Black individuals were more likely than White individuals to be hospitalized (OR=1.66, 95% CI: 1.21 to 2.28, p=.002) or admitted to the ED (OR=1.57, 95% CI: 1.16 to 2.13, p=.004) during their last month of life.
CONCLUSIONS: Findings have implications for informing healthcare decision making near the end of life for patients, families, and clinicians, especially in regions with a history of racial discrimination and disparities.
OBJECTIVES: For parents, family or clinicians of children with rare, life-threatening conditions there is little information regarding likely symptoms, illness trajectory and end-of-life care. This descriptive analysis of a bereaved cohort recruited in the Charting the Territory (CTT) study describes patient characteristics, symptoms, use of medications, discussion of resuscitation orders and care provided preceding and during the end-of-life.
METHODS: Of the 275 children enrolled in the CTT study, 54 died between 2009 and 2014. Baseline demographic information, symptoms, interventions and medical information were collected via chart review, interviews and surveys.
RESULTS: 51 of the 54 children had complete medical records. Of the seven symptoms evaluated, children were found to have an increase in median symptoms from baseline (n=2) to time of death (n=3). Opioids were used in the last 48 hours of life in 29 (56.9%) children, whereas only eight (15.7%) were receiving opioids at baseline. Do Not Attempt Resuscitation orders were in place at baseline in 17 (33.3%) children, increasing to 33 (64.7%) at time of death. Death occurred in a hospice setting in 16 (31.4%) children.
CONCLUSIONS: While much emphasis on pediatric palliative care has been on supportive treatment and symptom management, when faced with a lack of sound understanding of a rare illness, the mode of care can often be reactive and based on critical needs. By developing greater knowledge of symptoms and illness trajectory, both management and care can be more responsive and anticipatory, thereby helping ease illness burden and suffering.
The aim of supportive cancer care is to actively manage patients' physical, psychologic, and spiritual concerns, independent of prognosis. Complementary and integrative medicine (CIM) is increasingly gaining greater acceptance and support for its beneficial value in supportive cancer care. The utilization of CIM early in the cancer trajectory, during treatment and during survivorship periods, as well as during end of life, addresses a great number of unmet needs that patients affected by cancer raise. In addition, recent research supports the role that CIM has in reducing suffering and distress both physically and emotionally, as well as enhancing well-being in patients affected by cancer and their families. CIM is increasingly seen not only as an adjunctive add-on treatment or perhaps even as a luxury item for the affluent but actually as an important component in supportive cancer care for all patients. It addresses many aspects of care that sometimes are not being addressed with conventional means. With the increase in CIM-related research, as well as the increased clinical experience in oncology programs worldwide, CIM is gradually becoming an essential ingredient in supportive and palliative cancer care. In this narrative review, the authors look systematically at the contribution that CIM has in supportive care in each stage of the cancer trajectory, reflecting the needed role that CIM has in supportive care. The presented data will provide a sampling of the available clinical research for each of the broad stages being described.
OBJECTIVES: Patients with haematological malignancies (HM) receive more aggressive treatments near the end-of-life (EOL) than patients with solid tumours. Palliative care (PC) needs are less widely acknowledged in patients with multiple myeloma (MM) than in other HM. The main objective of our study was to describe EOL care and PC referral in a population of older patients with MM.
METHODS: We retrospectively included deceased inpatients and outpatients with an MM previously diagnosed at the age of 70 and over in two tertiary centres in France. We reported EOL characteristics regarding treatments considered to be aggressive-antimyeloma therapies, hospitalisations, blood product transfusions, intensive care units (ICUs) or emergency admissions-and PC referral.
RESULTS: We included 119 patients. In their last month of life, 75 (63%) were hospitalised for fever, pain, asthenia, anaemia or bleeding, 49 (41%) were admitted in the emergency department and 12 (10%) in ICU, 76 (64%) still received antimyeloma therapy and 45 (38%) had at least two transfusions. Only 24 (20%) received PC intervention for pain, global care, family support, anxiety, social care or confusion. Median follow-up until death was 20 days.
CONCLUSIONS: Our study found a high rate of hospitalisations and antimyeloma therapies in the last month of life. The PC referral rate was low, often once specific treatments were stopped. Our results suggest the need for more effective collaboration between PC teams and haematologists in order to respond to the specific needs of these patients and to improve their quality of care at EOL.
BACKGROUND: Indigenous Australians diagnosed with cancer have substantially higher cancer mortality rates compared with non-Indigenous Australians, yet there is a paucity of information about their end-of-life service utilisation and supportive care needs.
PURPOSE: To describe the service utilisation and supportive care needs of Aboriginal and Torres Strait Islander people with cancer at end-of-life.
METHOD: Hospital admission data were linked to self-reported data from a study of Indigenous cancer patients from Queensland, Australia during the last year of their life. Needs were assessed by the Supportive Care Needs Assessment Tool for Indigenous Cancer Patients which measures 26 need items across 4 domains (physical/psychological; hospital care; information/communication; practical/cultural). A descriptive analysis of health service utilisation and unmet needs was conducted.
RESULTS: In total, 58 Indigenous cancer patients were included in this analysis. All patients had at least one hospital admission within the last year of their life. Most hospital admissions occurred through emergency (38%) and outpatient (31%) departments and were for acute care (85%). Palliative care represented 14% of admissions and 78% died in hospital. Approximately half (48%) did not report any unmet needs. The most frequently reported moderate-to-high unmet need items were worry about the treatment results (17%), money worries (16%) and anxiety (16%).
CONCLUSIONS: Utilisation of palliative care services that manage a full range of physical and psychosocial needs was low. Addressing worries about treatment results, finances and generalised anxiety are priorities in this population.
OBJECTIVE: The diagnosis of an advanced cancer in young adulthood can bring one's life to an abrupt halt, calling attention to the present moment and creating anguish about an uncertain future. There is seldom time or physical stamina to focus on forward-thinking, social roles, relationships, or dreams. As a result, young adults (YAs) with advanced cancer frequently encounter existential distress, despair, and question the purpose of their life. We sought to investigate the meaning and function of hope throughout YAs' disease trajectory; to discern the psychosocial processes YAs employ to engage hope; and to develop a substantive theory of hope of YAs diagnosed with advanced cancer.
METHOD: Thirteen YAs (ages 23-38) diagnosed with a stage III or IV cancer were recruited throughout the eastern and southeastern United States. Participants completed one semi-structured interview in-person, by phone, or Skype, that incorporated an original timeline instrument assessing fluctuations in hope and an online socio-demographic survey. Glaser's grounded theory methodology informed constant comparative methods of data collection, analysis, and interpretation.
RESULTS: Findings from this study informed the development of the novel contingent hope theoretical framework, which describes the pattern of psychosocial behaviors YAs with advanced cancer employ to reconcile identities and strive for a life of meaning. The ability to cultivate the necessary agency and pathways to reconcile identities became contingent on the YAs' participation in each of the psychosocial processes of the contingent hope theoretical framework: navigating uncertainty, feeling broken, disorienting grief, finding bearings, and identity reconciliation.
SIGNIFICANCE OF RESULTS: Study findings portray the influential role of hope in motivating YAs with advanced cancer through disorienting grief toward an integrated sense of self that marries cherished aspects of multiple identities. The contingent hope theoretical framework details psychosocial behaviors to inform assessments and interventions fostering hope and identity reconciliation.
PURPOSE: Malignant bowel obstruction (MBO) is common in advanced GI cancer, and MBO management, including drainage percutaneous endoscopic gastrostomy (dPEG), is palliative. How patients understand the goals of dPEG and its impact on disease is inadequately understood in the literature. Therefore, we analyzed these issues in patients with GI cancer.
METHODS: Demographics, clinical variables, and patient outcomes were abstracted from the medical record. Illness understanding and future expectations were retrieved from palliative care notes. We described additional treatment and outcomes after dPEG and estimated overall survival (OS).
RESULTS: From January 2015 to June 2017, 125 admitted patients with metastatic GI cancer underwent dPEG for MBO. Cancers were most commonly colorectal (34%) and pancreatic/ampullary (25%). During the dPEG admission, 32% (40 of 125) of patients had a palliative care consultation, and 22% (28 of 125) were asked about illness understanding and future expectations. All (28 of 28) reported good understanding of the advanced nature of their disease, but few were accurate about prognosis given their stage IV disease (10 of 28). Of the 117 (94%) discharged, 13% (15 of 117) received additional chemotherapy, which rarely prevented progression; half (63 of 117) had a do-not-resuscitate order; and most (101 of 117) were enrolled in hospice at death. Median time to death was 37 days (95% CI, 29 to 45 days); 6-month OS was 3.7% (95% CI, 1.2% to 8.4%).
CONCLUSION: dPEGs are placed close to end of life in patients with advanced GI cancer. A minority of patients receive additional chemotherapy post-dPEG. Many have adequate disease understanding, but chemotherapy benefit is low, and future expectations vary. This may be an opportunity for improved communication regarding palliative procedures in advanced cancer.
OBJECTIVES: Advanced penile cancer is associated with a poor prognosis; therefore, providing patients with realistic expectations, addressing goals of care and offering palliative therapy when appropriate is critical. Our goal was to investigate the National Cancer Database (NCDB) and analyze the role and trends in use of palliative therapy in patients with advanced penile cancer.
METHODS: The NCDB 2004-2015 penile cancer data set was queried for patients with locally advanced, defined as cT4NanyM0 and cTanyN3M0, or metastatic disease regardless of tumor or nodal stage. Patients were categorized based on whether they did or did not receive palliative care. Palliative care was cataloged as pain management therapy, surgery, radiation or systemic treatment, any combination therapy or not otherwise specified (NOS). Our primary outcome was receiving palliative therapy. Secondary outcome was the temporal trends in palliative care. Logistic regression (LR) was performed.
RESULTS OBTAINED: 385 and 279 patients were identified with locally advanced and metastatic penile cancer respectively. 27 (7.1%) and 49 (17.6%) patients received palliative care. Average age of patients accepting palliative care was 61.9 years old, about 5 years younger than their counterparts who declined therapy (p < 0.011) in the metastatic cohort. Other patient specific demographics and clinical tumor characteristics were not significantly different in either population. Of patients with locally advanced disease pursuing palliative therapy, radiation (29.6%), surgery (14.8%), systemic treatment (14.8%) and combination treatment (22.2%) were the more popular choices. In the metastatic population, radiation (32.7%) and systemic therapy (24.5%) were the most prevalent choices for palliative treatment followed by combination treatment (16.3%), surgery (12.2%), pain management (10.2%), or NOS (4.1%). LR for the receipt of "any palliative therapy" revealed that increasing age (OR 0.971, p = 0.032) decreased the likelihood of accepting palliative therapy in the metastatic population but not in the locally advanced group. Charlson score of 2 (OR 5.966, p = 0.025) and low income (OR 3.968, p = 0.002) predicted receipt of palliative therapy in the locally advanced group. In patients with metastatic disease, African-American race (OR 2.502, p = 0.025), Charlson score 1 (2.175, p = 0.047) and 3+ (5.386, p = 0.020) predicted an increased predilection for receiving palliative therapy. Interestingly, no statistically significant difference in mortality was noted in either cohort. No significant increase in the trend of palliative care administration was seen in locally advanced and metastatic penile cancer between 2004 to 2015 (p = 0.078 and p = 0.942, respectively).
CONCLUSION: Locally advanced and metastatic penile cancer carry a high mortality rate yet only 11.4% of all patients studied received palliative care. Its use is more common in younger patients, those with co-morbidities and/or those of black race in the metastatic group. Locally advanced patients with low income or comorbidities were also more likely to opt for palliative therapy. Receipt of palliative care did not affect mortality. No increase in frequency of palliative therapy was seen, suggesting much improvement needs to be done in adopting and implementing palliative care in this patient population.
Patients with hematologic malignancies are thought to receive more aggressive end-of-life (EOL) care and have suboptimal hospice use compared with patients with solid tumors, but descriptions of EOL outcomes from comprehensive cohorts have been lacking. We used the population-based Surveillance, Epidemiology, and End Results-Medicare dataset to describe hospice use and indicators of aggressive EOL care among Medicare beneficiaries who died of hematologic malignancies in 2008-2015. Overall, 56.5% of decedents used hospice services for median 9 days (interquartile range, 3-27), 33.0% died in an acute hospital setting, 36.8% had an intensive care unit (ICU) admission in the last 30 days of life, and 13.3% received chemotherapy within the last 14 days of life. Hospice use was associated with 96% lower probability of inpatient death (adjusted risk ratio [aRR], 0.038; 95% confidence interval [CI], 0.035-0.042), 44% lower probability of an ICU stay in the last 30 days of life (aRR, 0.56; 95% CI, 0.54-0.57), and 62% decrease in chemotherapy use in the last 14 days of life (aRR, 0.38; 95% CI, 0.35-0.41). Hospice enrollees spent on average 41% fewer days as inpatient during the last month of life (adjusted means ratio, 0.59; 95% CI, 0.57-0.60) and had 38% lower mean Medicare spending in the last month of life (adjusted means ratio, 0.62; 95% CI, 0.61-0.64). These associations were consistent across histologic subgroups. In conclusion, EOL care quality outcomes and hospice enrollment were suboptimal among older decedents with hematologic cancers, but hospice use was associated with a consistent decrease in aggressive care at EOL.
PURPOSE: The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients.
METHODS: This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system.
RESULTS: In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders.
CONCLUSIONS: Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.