BACKGROUND: Despite the increasing use of erythropoiesis-stimulating agent (ESA) in patients receiving dialysis, few studies have examined the benefits of ESA for patients with chronic kidney disease receiving palliative care.
OBJECTIVE: We designed a retrospective observational study to evaluate the effect of ESA in treating anemia of renal disease among adult patients receiving palliative care instead of dialysis. The primary objective was to assess whether ESA can reduce the transfusion burden and hospitalization.
RESULTS: Thirty-nine patients receiving ESA were matched with a control group of 39 patients without ESA. Their mean age and glomerular filtration rates were 76.7 (10.2) years and 11.6 (5.7) mL/min/1.73 m2, respectively. Baseline hemoglobin levels were comparable in the ESA and control groups; their corresponding values were 10.2 (1.5) and 10.1 (1.4) g/dL. During 1-year observation period, 34 units of red cell transfusion occurred in patients receiving ESA, whereas 128 units of red cell were transfused to patients in control group. Patients in the control group had higher transfusion rate (incidence rate ratio [IRR]: 3.63; 95% confidence interval [CI]: 2.49-5.31; P < .00001) and higher admission rates (IRR: 2.34; 95% CI: 1.80-3.03; P < .000001) than the ESA group even after adjustment for comorbidities.
CONCLUSIONS: High disease burden of palliative care among patients with stage 4 to 5 chronic kidney disease was reflected by transfusion requirement and hospitalization rates, both of which were shown to be significantly ameliorated by ESA treatment.
Après 15 ans de recueil et d’enregistrement de données administratives et médicales, la Fédération Wallonne de soins palliatifs dispose de données chiffrées qui lui permettent de poser un regard rétrospectif sur l’activité des unités de soins palliatifs, à travers quelques items-clés, sur 4 années prises comme références. Dans cet article, la discussion portera sur le nombre de patients hospitalisés au sein de ces unités, les pourcentages de pathologies cancéreuses, la durée d’hospitalisation, l’origine des admissions, les pourcentages de réadmissions et les fins de séjour en unités. L’article se clôturera ensuite par quelques conclusions et perspectives pour l’avenir.
PURPOSE: The aim of the study was to evaluate the feasibility and the potential effects of the Haematological Home Care (HHC) programme for acute leukaemia (AL) patients, either in active chemotherapy or in the terminal phase of disease.
METHODS: We retrospectively assessed a group of AL patients assisted at home in terms of number of hospitalisations, accesses to emergency department and place of death. We also used historical data to evaluate potential effects of HHC.
RESULTS: The study group consisted of 44 patients, 36 of whom (82%) required palliative treatment, and eight (18%) had ongoing active chemotherapy. The mean number of hospitalisations was 0.64 (range 0-7) per patient, and the number of emergency department (ED) visits was 0.82 (range 0-4) per patient. Place of death was at home for 51.4% of patients and in hospital for 40.5%. Considering a historical group of 17 patients assisted at home the rate of hospitalisations and ED visits were 2.53 (range 0-9) and one (range 0-3), respectively. Place of death was home and hospital in 6% and 65%, respectively.
CONCLUSIONS: Haematological Home Care for AL patients is feasible and has potential positive effects in terms rate of hospitalisations and place of death.
BACKGROUND: Earlier palliative care consultation is associated with less intensive medical care and improved quality outcomes for patients with cancer. However, there are limited data about how the timing of palliative care affects utilization among noncancer patients exposed to palliative care consultation.
OBJECTIVE: Comparison of health care utilization for hospice decedents who received early versus late palliative care.
DESIGN: A retrospective cohort study utilizing hospital and hospice administrative databases.
SETTING/SUBJECTS: Patients with cancer and noncancer diagnoses who received specialty palliative care consultation before dying at a local hospice.
MEASUREMENTS: Comparing early (>90 days before death) versus late (<90 days before death) palliative care, outcome measures included intensive care unit (ICU) utilization and hospice length of stay (LOS).
RESULTS: Of 233 hospice decedents in 2014 who had palliative care referrals, 36 (15.4%) had early and 197 (84.5%) had late referrals. Nearly half of the patients had a noncancer hospice diagnosis. Only 6% of the early group used the ICU in the last month of life, whereas 56% of the late group did. Patients receiving early palliative care had a longer median hospice LOS than those with late palliative care (138 days vs. 8 days).
CONCLUSIONS: Early palliative care appears to reduce intensive medical care and increase hospice LOS for patients with a variety of end-stage diseases.
Background: The impact of specialty pediatric palliative care (PPC) on intensive care unit (ICU) length of stay for children is unclear.
Objective: To estimate the impact of PPC consultation by analyzing ICU stay as a dynamic outcome over the course of hospitalization.
Patients and Methods: Retrospective cohort study of children hospitalized with diagnoses suggested as referral triggers for PPC at a large academic children's hospital. We assessed ICU stay according to PPC consultation and, using a patient-day analysis, applied multivariable mixed effects logistic regression to predict the odds of being in the ICU on a given day.
Results: The analytic sample included 777 admissions (11,954 hospital days), of which 100 admissions (13%) included PPC consultation. Principal patient demographics were age 8 ± 6 years, 55% male sex, 71% white race, and 52% commercial insurance. Cardiac diagnoses were most frequent (29%) followed by gastrointestinal (22%) and malignant (20%) conditions. Although total ICU stay was longer for admissions, including PPC consultation (compared to admissions where PPC was not consulted), the odds of being in the ICU on a given day were reduced by 79% after PPC consultation (odds ratio [OR] = 0.21; 95% confidence interval [CI]: 0.13–0.34; p < 0.001) for children with cancer and 85% (OR = 0.15; 95% CI: 0.08–0.26; p < 0.001) for children with nononcologic conditions.
Conclusions: Among children hospitalized with a diagnosis deemed eligible for specialty PPC, the likelihood of being in the ICU on a given day was strongly reduced after PPC consultation, supporting the value of PPC.
OBJECTIVES: The current evidence base regarding the effectiveness of home-based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end-of-life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO).
DESIGN: Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016.
SETTING: Kaiser Permanente Southern California.
PARTICIPANTS: Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal-HO = 22 472).
MEASUREMENTS: Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF).
RESULTS: Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal-HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal-HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal-HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58-.87) and SNF stays (RR = .32-.77) compared with both HO and No HomePal-HO patients.
CONCLUSION: Earlier comprehensive palliative care in patients’ home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life.
BACKGROUND: Hospital-based palliative care consultation is consistently associated with reduced hospitalization costs and more importantly with improved patient quality of life. As healthcare systems move toward value-based purchasing rather than fee-for-service models, understanding how palliative care consultation is associated with value-based purchasing metrics can provide evidence for expanded health system support for a greater palliative care presence.
AIM: To understand how a palliative care consultation impacts rates of patient readmission and hospital-acquired infections associated with value-based purchasing metrics.
DESIGN: Retrospective propensity-matched case-control study evaluating the impact of palliative care consultation on hospital charges, hospital and intensive care unit length of stay, readmission rates, and rates of hospital-acquired conditions.
SETTING/PARTICIPANTS: All adult patients admitted to a two hospital healthcare system over a 2-year period from 1 April 2015 to 31 March 2017. The palliative care team involved three physicians, five advanced practice providers, a social worker, and a chaplain during the study period.
RESULTS: A total of 3415 patients receiving a palliative consult were propensity matched to 25,028 controls. Compared to controls, cases had decreased charges per day and decreased rates of 7-, 30-, and 90-day readmissions.
CONCLUSION: Through value-based purchasing, hospitals have 3% of their Medicare reimbursements at risk based on readmission rates. By clarifying prognosis and patient goals, palliative care consultation reduces readmission rates. Hospital systems may want to invest in larger palliative care programs as part of their efforts to reduce hospital readmissions.
BACKGROUND: Although bereavement is likely a common stressor among patients referred to a psychotrauma clinic, no study has yet examined the co-occurrence and relationships between symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and major depressive disorder symptoms in this population.
METHOD: In a sample of patients seeking treatment following psychological trauma (n = 458), we used latent class analysis to identify classes of patients sharing the same profile of PGD, PTSD, and depression symptoms. We then used network analysis to investigate the relationships among these symptoms and with loss-related variables.
RESULTS: Most participants (65%) were members of a class that exhibited elevated endorsement of PGD symptoms. PGD, PTSD, and depression symptoms hung together as highly overlapping but distinguishable communities of symptoms. Symptoms related to social isolation and diminished sense of self bridged these communities. Violent loss was associated with more difficulty accepting the loss. The loss of close kin was most strongly associated with difficulty moving on in life.
CONCLUSIONS: PGD symptoms are common in trauma-exposed bereaved adults and closely associated with symptoms of PTSD and depression, illustrating the importance of assessing bereavement and PGD symptoms in those seeking treatment following trauma.
Patients with chronic illness are associated with high health-care utilization and this is exacerbated in the end of life, when health-care utilization and costs are highest. Complex Care Management (CCM) is a model of care developed to reduce health-care utilization, while improving patient outcomes. We aimed to examine the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in CCM over the last 2 years of life. Generalized estimating equation models were used. The sample (n = 126) was 52% female with an average age of 85 years. Health-care utilization rose sharply in the last 3 months of life with at least one hospitalization for 67% of participants and an emergency department visit for 23% of participants. In the last 6 months of life, there was an average of 2.17 care transitions per participant. The odds of hospitalization increased by 27% with each time interval ( P < .001). Participants demonstrated 11% greater odds of having a hospitalization for each additional comorbidity ( P = .05). A primary diagnosis of heart failure or coronary artery disease was associated with 21% greater odds of hospitalization over time compared to other primary diagnoses ( P = .017). Females had 70% greater odds of an emergency department visit compared to males ( P = .046). For each additional year of life, the odds of an emergency department visit increased by about 7% ( P < .001). Findings suggest the need for further interventions targeting chronically ill older adults nearing end of life within CCM models.
Health care professionals use teach-back to foster adherence to treatment recommendations and to improve safety and quality of care. This improvement project, conducted in one division of a home care agency, used a pretest-posttest design with an interprofessional group of hospice home care clinicians to incorporate teach-back into home visits to evaluate if the use of teach-back enhanced caregiver and patient-provider communication, improved caregivers' confidence in caring for hospice home care patients, and decreased hospitalizations. After the intervention, the teach-back group had zero hospitalizations compared with 2 for the non–teach-back group (0% and 1.97%, respectively), and patient-caregiver “confidence” increased from 58% to 81%, pre to post intervention. In conclusion, teach-back is a cost-effective teaching methodology that can be implemented by any discipline to improve patient-provider communication and patient outcomes.
This study aimed to determine the range of mean cumulative corticosteroid doses that could effectively palliate dyspnea in opioid-treated patients with terminal cancer and to investigate the demographic or biochemical factors predictive of corticosteroid responsiveness. To this end, responders and nonresponders were compared with regard to corticosteroid dose and whether they had initiated opioid use before or concomitantly with corticosteroid use. A logistic regression analysis was conducted to assess the impacts of demographic and biochemical factors on corticosteroid effectiveness. The final sample comprised 20 patients who satisfied the selection criteria. The responders accounted for 70% of the total sample (n = 14) and experienced the strongest effect with regard to dyspnea palliation at a mean cumulative dose equivalent to 64.4 mg prednisolone. However, no factors predictive of response were identified. In summary, this retrospective study identified effective corticosteroid doses for dyspnea alleviation in terminal cancer patients. Although our study sample was limited in size, the results support further prospective research.
BACKGROUND: Despite growth in service availability, palliative care (PC) referrals are often underutilized or delayed, which may compromise patient outcomes.
LOCAL PROBLEM: Underutilized or delayed PC referrals among hospitalized adults prompted this project aimed at improving PC measures, quality, and utilization outcomes.
METHODS: Data extracted from the electronic medical record were used to identify needed improvements in PC.
INTERVENTION: Interdisciplinary rounds (IDRs) were implemented on the hospitalist service in a nonintensive care setting.
RESULTS: Following implementation, median time to PC referral decreased by 2 days. Length of stay (LOS), direct cost, and 30-day mortality also decreased. Postintervention patients were more likely to transition home compared with another facility.
CONCLUSIONS: Results support IDRs as a mechanism to improve time to PC referral, decrease LOS, direct cost, and 30-day mortality among hospitalized adults. A more objective method of identifying patients with unmet PC needs may be warranted.
BACKGROUND: Despite their poor prognosis, patients with severe chronic obstructive pulmonary disease (COPD) have little access to palliative care and tend to have a high rate of hospital and intensive care unit (ICU) admissions during their last year of life.
OBJECTIVES: To determine the feasibility of a home palliative care intervention during 1 year versus usual care, and the possible impact of this intervention on emergency, hospital and ICU admissions, survival, mood, and health-related quality of life (HRQL).
METHODS: Prospective controlled study of patients with severe COPD (GOLD stage III or IV) and long-term oxygen therapy and/or home noninvasive ventilation and/or one or more hospital admissions in the previous year for acute exacerbation, randomized to usual care versus usual care with add-on monthly intervention by palliative care specialists at home for 12 months.
RESULTS: Of 315 patients screened, 49 (15.5%) were randomized (26 to early palliative care; 23 to the control group); aged (mean ± SD) 71 ± 8 years; FEV1 was 37 ± 14% predicted; 88% with a COPD assessment test score > 10; 69% on long-term oxygen therapy or home noninvasive ventilation. The patients accepted the intervention and completed the assessment scales. After 1 year, there was no difference between groups in symptoms, HRQL and mood, and there was a nonsignificant trend for higher admission rates to hospital and emergency wards in the intervention group.
CONCLUSION: Although this pilot study was underpowered to formally exclude a benefit from palliative care in severe COPD, it raises several questions as to patient selection, reluctance to palliative care in this group, and modalities of future trials.
BACKGROUND: Lung cancer is the leading cause of cancer deaths globally. Individuals are diagnosed at an advanced stage with limited life expectancy.
OBJECTIVES: To explore potential health disparities in hospice utilization and length of stay (LOS) in a diverse sample of patients with lung cancer.
METHODS: Demographic and clinical information as well as data for hospice utilization and LOS was extracted from electronic health records. Data were analyzed using descriptive statistics, 2 tests, and an analysis of variance test.
RESULTS: Data from 242 patients were analyzed. In the sample, 33% (n = 80) were Black and 51% (n = 124) lived in a rural county. At the time of data collection, 67% of the sample was deceased and 36% (n = 86) chose to enroll in hospice. No disparities were found for race, age, gender, or rural/urban dwellers in hospice enrollment. No disparities were found for race, gender, or rural/urban dwellers for hospice LOS. Age was associated with hospice LOS ( P = .004). Those who were older were more likely to have a longer LOS.
CONCLUSION: Hospice utilization and LOS were low for all groups with lung cancer in a geographically and racially diverse region of the United States. Given the rates of mortality in lung cancer, discussions about the goals and benefits of hospice care may be beneficial and should be part of an ongoing dialogue throughout the disease trajectory.
BACKGROUND: One-quarter of all cancer deaths in Sweden occur in hospitals. If the place of death affects the quality of end-of-life (EOL) is largely unknown.
METHODS: This population-based, retrospective study included all adults cancer deaths reported to the Swedish Register of Palliative Care in 2011â€“2013 (N = 41,729). Hospital deaths were compared to deaths occurring in general or specialised palliative care, or in nursing homes with respect to care quality indicators in the last week of life. Odds ratios (OR) with 95% confidence intervals (CI) were calculated with specialised palliative home care as reference.
RESULTS: Preferred place of death was unknown for 63% of hospitalised patients and consistent with the actual place of death in 25% compared to 97% in palliative home care. Hospitalised patients were less likely to be informed when death was imminent (OR: 0.3; CI: 0.28-0.33) as were their families (OR: 0.51; CI: 0.46-0.57). Validated screening tools were less often used in hospitals for assessment of pain (OR: 0.32; CI: 0.30-0.34) or other symptoms (OR: 0.31; CI: 0.28-0.34) despite similar levels of EOL symptoms. Prescriptions of as needed drugs against anxiety (OR: 0.27; CI: 0.24-0.30), nausea (OR: 0.19; CI: 0.17-0.21), or pulmonary secretions (OR: 0.29; CI: 0.26-0.32) were less prevalent in hospitals. Bereavement support was offered after 57% of hospital deaths compared to 87-97% in palliative care units and 72% in nursing homes.
CONCLUSIONS: Dying in hospital was associated with inferior end-of-life care quality among cancer patients in Sweden.
BACKGROUND: The supporting role of caregivers is crucial to cancer patients' care and well-being. Periods of inpatient hospital treatment are common in the cancer trajectory. There is insufficient systematic knowledge of caregivers' experiences and information needs in hospital context.
AIM: Aim of this study is to identify information needs and factors contributing to unmet information needs of caregivers in hospital.
DESIGN: A qualitative approach was used to identify major themes and specific types of information needs. Interviews with caregivers were conducted and analysed using a qualitative three-step process.
SETTING/PARTICIPANTS: The study was conducted in a hospital oncology department. Seventeen caregivers of patients with advanced cancer were interviewed.
RESULTS: Caregivers' needs during inpatient treatment vary and are largely unmet. Four major themes emerged from the analysis, revealing information needs of caregivers related to the cancer disease, patient, caregivers themselves and hospital context. The most mentioned issues were appropriate treatment, treatment outcomes and the related consequences for caregivers' life, hospital processes and transition back home.
CONCLUSION: Caregivers have a variety of specific information needs which often remain unmet. Based on our findings, we provide recommendations for integrating caregivers into oncology care, which should be implemented in clinical practice, policy decisions and research.
Aim: Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have become a reasonably safe procedure with acceptable morbidity and mortality rate. However, little is known regarding the incidence, trends, and predictors of palliative care (PC) consult in aortic valve replacement (AVR) patients. The main purpose of this analysis was to assess the incidence, trends, and predictors of PC consultation in AVR recipients using the Nationwide Inpatient Sample (NIS) database.
Materials and Methods: We queried the NIS database from 2005 to September 2015 to identify those who underwent TAVR or SAVR and had PC referral during the index hospitalization. Adjusted odds ratio (aOR) was calculated to identify patient demographic, social and hospital characteristics, and procedural characteristics associated with PC consult using multivariable regression analysis. We also reported the trends of PC referral in AVR recipients.
Results: A total of 522 765 admissions (mean age: 75.3 ± 7.8 years, 40.3% female) who had TAVR (1.7% transapical and 9.2% endovascular approach) and SAVR (89.2%) were identified. Inpatient mortality was 3.96%, and 0.5% patients of the total admissions had PC consultation. The PC referral for SAVR increased from 0.90 to 7.2 per 1000 SAVR from 2005 to 2015 (P = .011), while it remained stable ranging from 9.30 to 13.3 PC consults per 1000 TAVR (P = .86). Age 80 to 89 (aOR: 1.93), age =90 years (aOR: 2.57), female sex (aOR: 1.36), electrolyte derangement (aOR: 1.90), weight loss (aOR: 1.88), and do not resuscitate status (aOR: 44.4) were associated with PC consult. West region (aOR: 1.46) and Medicaid (aOR: 3.05) were independently associated with PC consult. Endovascular (aOR: 1.88) and transapical TAVR (aOR: 2.80) had higher PC referral rates compared with SAVR.
Conclusions:There was an increase in trends for utilization of PC service in SAVR admissions while it remained unchanged in TAVR cohort, but the overall PC referral rate was low in AVR recipients during the index hospitalization.
Background: Accurate population-based data regarding hospital-based care utilisation by older persons during their last year of life are important in health services planning. We investigated patterns of acute hospital-based service use at the end of life, amongst older decedents in New South Wales (NSW), Australia.
Methods: Data from all persons aged =70 years who died in the state of NSW Australia in 2007 were included. Several measures of hospital-based service utilisation during the last year of life were assessed from retrospectively linked data comprising data for all registered deaths, cause of death, hospital care during the last year of life (NSW Admitted Patient Data Collection [APDC] and Emergency Department [ED] Data Collection [EDDC]), and the NSW Cancer Registry.
Results: Amongst 34,556 decedents aged =70 years, 82% (n = 28,366) had =1 hospitalisation during the last year of life (median 2), and 21% > 3 hospitalisations. Twenty-five percent (n = 5485) of decedents attended ED during the last week of life. Overall, 21% had a hospitalisation > 30 days in the last year of life, and 7% spent > 3 months in hospital; 79% had =1 ED attendance, 17% > 3. Nine percent (n = 3239) spent time in an intensive care unit. Fifty-three percent (n = 18,437) died in an inpatient setting. Hospital records had referenced palliative care for a fifth (7169) of decedents. Adjusting for age group, sex, place of residence, area-level socioeconomic status, and cause of death, having > 3 hospitalisations during the last year of life was more likely for persons dying from cancer (35% versus 16% non-cancer deaths, adjusted odds ratio [aOR] 2.33), â€˜youngerâ€™ old decedents (29% for age 70â€“79 and 20% for age 80â€“89 versus 11% for 90+, aOR 2.42 and 1.77 respectively) and males (25% versus 17% females, aOR 1.38). Patterns observed for other hospital-based service use were similar.
Conclusions: This population-based study reveals high use of hospital care among older persons during their last year of life, although this decreased with increasing older age, providing important data to inform health services planning for this population, and highlighting aspects requiring further study.
BACKGROUND: Our recent research suggests that a fluctuating trajectory, previously thought to be the experience of those dying with heart failure or chronic lung disease, may not accurately characterize the end of life for these patients.
OBJECTIVE: We sought to further examine health and function to investigate whether other measures or a different time frame captures the purported exacerbation/recovery trajectory associated with these diseases.
DESIGN: Function and health data were collected prospectively at six-month intervals for 17 years during the Heath, Aging and Body Composition Study.
SUBJECTS AND MEASURES: We analyzed self-reported mobility, health status, and health care utilization for 1410 decedents, defining high fluctuations as transitions in two or more adjacent assessment pairs during the last three years of life.
RESULTS: Among decedents, only 207 (14.7%) reported two or more changes in mobility during the last three years of life; and 586 (41.6%) reported more than two transitions in self-reported health during the period. This fluctuation was not associated with any clinical condition in the three years before death, but decedents with chronic heart failure or chronic lung disease reported significantly more changes in mobility (odds ratio = 1.15, p = 0.025) for a longer follow-up period. Decedents with heart failure were also more likely to report hospital stays in the last three years of life.
CONCLUSIONS: Fluctuations in mobility and self-reported health do not differ by clinical condition in the three years before death, but people dying with chronic heart failure or chronic lung disease are more frequently hospitalized during this period and experience more unstable mobility for a longer period of observation.
This study was conducted to investigate the trajectory of hospitalization costs, and to assess the determinants related to the membership of the identified trajectories, with the view of recommending future research directions. A retrospective study was performed in urban Yichang, China, where a total of 134 end-stage lung cancer patients were selected. The latent class analysis (LCA) model was used to investigate the heterogeneity in the trajectory of hospitalization cost amongst the different groups that were identified. A multi-nominal logit model was applied to explore the attributes of different classes. Three classes were defined as follows: Class 1 represented the trajectory with minimal cost, which had increased over the last two months. Classes 2 and 3 consisted of patients that incurred high costs, which had declined with the impending death of the patient. Patients in class 3 had a higher average cost than those in Class 2. The level of education, hospitalization, and place of death, were the attributes of membership to the different classes. LCA was useful in quantifying heterogeneity amongst the patients. The results showed the attributes were embedded in hospitalization cost trajectories. These findings are applicable to early identification and intervention in palliative care. Future studies should focus on the validation of the proposed model in clinical settings, as well as to identify the determinants of early discharge or aggressive care.