Head and neck cancer affects vital functions of speech, swallowing, breathing, and appearance. Overall survival remains poor and symptom burden is high for both patients with incurable disease at the end of life and for long-term survivors. Early and concurrent palliative care helps guide treatment decision making and support quality of life during and after treatment. Both narrative competence and directive counsel can affect the concordance of patient goals and tolerance of treatment and outcomes.
PURPOSE: Despite clear benefits of early integration of palliative care (PC) and oncology, concerns remain about negative perceptions of PC. Our aim was to explore current knowledge and perceptions of PC in cancer patients.
METHODS: We conducted a prospective, cross-sectional survey. A 16-item questionnaire was distributed to all cancer patients (N=103) upon admission to the oncology ward of an Australian tertiary academic hospital. Chi-squared test was used to examine for significant factors related to patients' perceptions.
RESULTS: Ninety-six patients (93%) completed the questionnaire; 76% had metastatic cancer. We explored the following domains: Experience and knowledge: 76% had heard of PC; 21% had received PC. Self-rated PC knowledge was varied. Forty-five percent believed that PC was only associated with EOLC; those more likely to disagree had received PC services (p=0.039). Integration of PC and oncology: Majority believed that they could receive oncology care (86%) and anti-cancer treatment (81%) whilst receiving PC. Those who had heard of PC and with better self-rated knowledge were more likely to believe that they could receive concurrent anti-cancer treatment (p=0.005, p=0.045, respectively). Feelings: 77% felt comforted with PC involvement; this was significantly associated with older age (p=0.047) and understanding that oncology (p<0.005) and anti-cancer treatment (p=0.013) could continue. However, some felt frightened (40%) and hopeless (29%) about referral to PC. Fifty percent felt more comfortable with referral to 'supportive care' services (versus PC).
CONCLUSIONS: Our survey demonstrates reasonable understanding and relatively positive feelings about PC, associated with experience and knowledge. Nonetheless, there is ongoing need for better patient and public education about PC.
Background: Palliative care aims to improve quality of life for patients with life-limiting illnesses. It is often linked to the care of people with cancer; however, patients with non-cancer end-stage conditions also have significant needs.
Objectives: The aims of this paper are to discuss common trajectories of deterioration in non-malignant conditions, consider possible barriers to palliative care referral, review the principles of the palliative care approach and illustrate specific factors relevant for common non-cancer conditions.
Discussion: The symptom burden and care needs for patients with end-stage, nonmalignant illnesses are similar to those of patients with advanced cancer. These patients benefit from a palliative approach, comprising management of the underlying condition and attention to symptoms, psychosocial needs and carer support. Advance care planning provides an opportunity to prepare for future illness episodes, including provision of end-of-life care. General practitioners are well placed to provide palliative care for patients with advanced non-cancer illnesses.
Studies of terrorism-related deaths are few and mostly focus on short-term effects. To characterize long-term bereavement outcomes, including resilience/recovery and patterns of comorbidity, following the September 11, 2001 (9/11), terrorist attacks, we report mental health conditions and grief-related impairment in 454 9/11 bereaved family members. In addition, the contribution of non-9/11 lifetime traumas, pre-9/11 mental health conditions, post-9/11 interim life events, grief services, income adequacy, and social support were examined. Latent class analyses yielded three groups: healthy, comorbid without PTSD (comorbid/noPTSD), and comorbid with PTSD and impaired (comorbid/PTSD+I). Participants in the healthy group (66.1%) were least likely to meet thresholds for mental conditions, whereas those in the comorbid/noPTSD (21.3%) and comorbid/PTSD+I (12.6%) groups had higher probabilities of meeting depression, grief, and anxiety thresholds. These groups also endorsed more negatively valenced post-9/11 interim life events than the healthy group: comorbid/noPTSD vs. healthy, odds ratio (OR) = 0.84, 95% CI [0.76, 0.94]; comorbid/PTSD+I vs. healthy, OR = 0.85, 95% CI [0.76, 0.96]. Comorbid/PTSD+I was the only group with elevated probabilities of meeting clinical thresholds for PTSD (.64) and grief-related impairment (.94). This group was also more likely to include bereaved parents: comorbid/PTSD+I vs. healthy, OR = 12.96, 95% CI [1.97, 85.41]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 15.55, 95% CI [1.63, 148.41]); and to experience more non-9/11 lifetime traumas: comorbid/PTSD+I vs. healthy, OR = 4.34, 95% CI [1.28, 14.70]; comorbid/PTSD+I vs. comorbid/noPTSD, OR = 6.54, 95% CI [1.53, 27.95]. Clinical and community programs should target this high-risk group to identify individuals in need of services.
Introduction: Studies have shown aggressive cancer care at the end of life is associated with decreased quality of life, decreased median survival, and increased cost of care. This study describes the patients most likely to receive systemic anticancer therapy at the end of life in a community cancer institute.
Materials and Methods: We performed a retrospective cohort study of 201 patients who received systemic anticancer therapy in our institution and died between July 2016 and April 2017. Data collected included primary malignancy, hospice enrollment, healthcare utilization, Oncology Care Model (OCM) enrollment, and clinical assessments at last office visit prior to a treatment decision before death. We defined our outcome variable as the receipt of anticancer treatment in the last 14 days of a patient's life. We evaluated 20 clinical exposure variables with respect to the outcome classes. Risk ratios along with their associated confidence intervals and P values were calculated. Significance was determined using the Benjamini-Hochberg procedure to account for multiple testing.
Results: Of the 201 patients who died of cancer, 36 (17%) received anticancer therapy within the last 14 days of life. Several risk factors were significantly positively associated with receiving anticancer therapy at the end of life including hospitalization within 30 days of end of life, number of hospitalizations per patient (=2), death in hospital, enrollment in OCM, and a diagnosis of hematologic malignancy.
Conclusion: Our findings demonstrate those enrolled in the OCM and those with hematologic malignancies have a higher risk of receiving anticancer therapy in the last 14 days of life. These observations highlight the need for better identifying the needs of high-risk patients and providing good quality care throughout the disease trajectory to better align end-of-life care with patients' wishes.
PURPOSE: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician.
METHODS: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life.
RESULTS: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001).
CONCLUSIONS: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.
BACKGROUND: High rates of health care utilization at the end of life may be a marker of care that does not align with patient-stated preferences. We sought to describe trends in end-of-life care and factors associated with dying in hospital.
METHODS: We conducted a population-level retrospective cohort study of adult decedents in Ontario between Apr. 1, 2004, and Mar. 31, 2015, using linked administrative data sets, including the Office of the Registrar General for Deaths database, the hospital Discharge Abstract Database, the National Ambulatory Care Reporting System and physicians' billing claims (Ontario Health Insurance Plan). The primary outcome was place of death. To determine health care utilization and health care costs during the 6 months before death, we also identified admissions to hospital and to the intensive care unit, emergency department visits, and receipt of mechanical ventilation and palliative care.
RESULTS: In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ventilation. Forty-five percent of all deaths occurred in hospital, a proportion that declined marginally over time, whereas receipt of palliative care increased during terminal hospital admissions (from 14.0% in fiscal year 2004/05 to 29.3% in 2014/15, p < 0.001) and in the last 6 months of life (from 28.1% in 2004/05 to 57.7% in 2014/15, p < 0.001). The proportion of decedents who presented to the emergency department, were admitted to hospital or were admitted to the intensive care unit in the last 6 months of life did not change over 11 years. The mean total health care costs in the last 6 months of life were highest among those dying in hospital, with most costs attributable to inpatient medical care.
INTERPRETATION: Health care utilization in the last 6 months of life was substantial and did not decrease over time. It is possible that increased capacity for palliative, hospice and home care at the end of life may help to better align health system resources with the preferences of most patients, a topic that should be explored in future studies.
BACKGROUND: transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable.
OBJECTIVE: to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia.
DESIGN: retrospective cohort study.
SETTING: electronic records from a mental health provider in London, linked to national mortality and hospital data.
SUBJECTS: people with dementia who died in 2007-2016.
METHODS: end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression.
RESULTS: of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11-1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49-0.97), physical illness (OR 1.52, 95% CI 1.20-1.94), depressed mood (OR 1.49, 95% CI 1.17-1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37-0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001).
CONCLUSIONS: in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.
Objective To investigate symptom-relief and comorbid drug uses at the end of life for older people with different dying trajectories (cancer, organ failure, frailty and sudden death) in Taiwan.
Methods In a retrospective observational study of older people aged 65 years and older who died in hospitals between 2008 and 2012, we used NHIRD to measure numbers, incremental changes and determinants of symptom-relief and comorbid drug use in the last month of outpatient care and last hospitalisation before death.
Results We included 59 407 older adults (cancer 37%, organ failure 26%, frailty 35% and sudden death 2%) who died in hospitals for this study. In the last hospitalisation before death, individuals who died of cancer received greatest number of symptom-relief drugs (mean: 4.65, [SD 2.77]) and increased most the average change in the number of symptom-relief drug use (+1.60; SD 3.36). However, individuals who died of organ failure received the highest number of comorbid drugs (mean 2.88, [SD 1.95]) and also increased most the average change in the number of comorbid drug use (+0.17; SD 2.28) at last hospitalisation. Different dying trajectories were key determinants of receiving symptom-relief and comorbid drugs in our study.
Conclusions Our study suggests that the drug use of older adults at the end of life in the cancer group is different from that in the organ failure and frailty groups. Policymakers and health professionals should consider the different strategies to optimise drug use for older people with different dying trajectories near their end of life.
OBJECTIVES: Studies have shown improved patient quality of life with supportive care rather than aggressive treatment at the end of life. This study evaluated the symptoms that patients in Thailand with gynecologic cancers experienced and the interventions that they received at the end of life.
METHODS: The medical records of patients admitted to a tertiary cancer center in Thailand who died in the hospital from gynecologic malignancies between January 1, 2011 and December 31, 2016 were reviewed. Inclusion criteria were patients who had been been diagnosed with gynecologic cancers (ovarian, endometrial, cervical, vulvar, or peritoneal cancers or uterine sarcomas) and had died in the hospital during that period. Patients whose medical records were incomplete or unavailable were excluded from the study. Data on demographics, symptoms, interventions, and end-of-life care were collected.
RESULTS: A total of 159 patients were included in this analysis. The mean age at death was 54.3 (range 15-91) years. Over half (54.7%) of the patients were diagnosed with ovarian or peritoneal cancer, 26.4% with uterine cancer or sarcoma, 16.4% with cervical cancer, and 1.3% with dual primary cancers. Symptoms at time of admission were poor oral intake (68.6%), abdominal distention or discomfort (63.5%), pain (42.8%), nausea or vomiting (35.2%), and fever or signs of infection (27.0%). The mean number of hospitalizations during the last 6 months was 3.6. Thirty-six patients (22.6%) had major surgery during the last 6 months of life, with 14 patients (8.8%) having it performed during their last admission before death. The mean length of the last hospital stay was 22.3 (range 6-31) days, and 61 patients (38.4%) were admitted to the intensive care unit. Eleven patients (6.9%) had chemotherapy in their last 14 days of life and 10 (6.3%) received cardiopulmonary resuscitation. Almost all patients (153, 96.2%) had do-not-resuscitate (DNR) consents. The mean time between the DNR consent and death was 6.3±9.7 days.
CONCLUSION: Multiple hospital admissions, aggressive treatments, and invasive procedures were common among patients with gynecologic cancer at the end of life. Better symptom management, end-of-life preparation, and communication are needed to enhance patients' quality of life in Thailand.
Background: Dementia is a terminal illness making the palliative and hospice approach to care appropriate for older people with advanced dementia.
Objective: To examine clinical and health services outcomes of a quality improvement pilot project to provide home hospice care for older people with advanced dementia.
Study design: Twenty older people with advanced dementia being treated in the Maccabi Healthcare Services homecare program, received home hospice care as an extension of their usual care for 6–7 months (or until they died) from a multidisciplinary team who were available 24/7. Family members were interviewed using validated questionnaires about symptom management, satisfaction with care, and caregiver burden. Hospitalizations prevented and medications discontinued, were determined by medical record review and team consensus.
Findings: The findings are based on 112 months of care with an average of 5.6 (SD 1.6) months per participant. The participants were on average 83.5 (SD 8.6) years old, 70% women, in homecare for 2.8 (SD 2.0) years, had dementia for 5.6 (SD 3.6) years with multiple comorbidities, and had been hospitalized for an average of 14.0 (SD 18.1) days in the year prior to the project. Four patients were fed via artificial nutrition. During the pilot project, 4 patients died, 2 patients withdrew, 1 patient was transferred to a nursing home and 13 returned to their usual homecare program. The home hospice program lead to significant (p < 0.001)improvement in: symptom management (score of 33.8 on admission on the Volicer symptom management scale increased to 38.3 on discharge), in satisfaction with care (27.5 to 35.3,), and a significant decline in caregiver burden (12.1 to 1.4 on the Zarit Burden index). There were five hospitalizations, and 33 hospitalizations prevented, and an average of 2.1(SD 1.4) medications discontinued per participant. Family members reported that the professionalism and 24/7 availability of the staff provided the added value of the program.
Conclusions: This pilot quality improvement project suggests that home hospice care for older people with advanced dementia can improve symptom management and caregiver satisfaction, while decreasing caregiver burden, preventing hospitalizations and discontinuing unnecessary medications. Identifying older people with advanced dementia with a 6 month prognosis remains a major challenge.
PURPOSE: It is imperative to provide quality end-of-life (EOL) care for patients with cancer. Although rates of hospice use within the Veterans Health Administration have improved, antineoplastic administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, have not clearly declined over recent years.
METHODS: We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009 and 2016 using a novel EOL Dashboard Tool created from Veterans Administration Cancer Registry data. This EOL tool reports the incidence of antineoplastic drug use in the last 14 days of life, ICU admission in the last 30 days of life, and hospice admission or consult. Change from 2009 to 2016 was assessed using a repeated measures one-way analysis of variance with post hoc test for linear trend of time for individual cancers and two-way analysis of variance for all cancers combined.
RESULTS: Antineoplastic use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 (P = .03). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was patients with stage IV lung cancer, in whom ICU admissions increased from 12.9% to 16.2% (P = .01). Patients using hospice services increased from 32.4% to 52.6% (P < .01).
CONCLUSION: Although antineoplastic administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice use.
CONTEXT: The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home.
OBJECTIVES: To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients.
METHODS: This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regression was used to evaluate outcomes according to patients' receipt of intervention(s).
RESULTS: The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (p < 0.0001). Compared to patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk=2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalizations or emergency department visits in the six months prior to death.
CONCLUSION: Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end-of-life. This association was stronger when these interventions were used together.
CONTEXT: Palliative care in oncology provides multiple benefits, however access to specialty palliative clinicians is limited in community cancer centers. Individual support services are more often available, but little is known on the utilization and impact of these services.
OBJECTIVES: To describe the utilization of outpatient support services in the advanced cancer population and the association with ED and hospital use in a community setting.
METHODS: A retrospective chart review of 314 patients with advanced cancer of lung, gastrointestinal, genitourinary, and gynecologic origin was conducted. Data collected included demographics, descriptive data, type and number of support services (symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor) within 90 days of diagnosis and descriptions of ED visits/hospitalizations within 12 months of diagnosis. Support services were available to patients by referral.
RESULTS: 29.6% of patients were deceased within 6 months and were considered to have severe disease. Patients with severe disease had a significantly greater mean number of support services than patients with non-severe disease (8.9 vs 6.0, p=0.001) and had a greater mean number of visits per year to the ED (6.4 vs 1.8, p<0.001). A greater proportion of patients with severe disease had palliative consultations (48.9% vs 21.7%, p<0.001), but 65.5% of palliative consultations occurred after an ED or hospital visit.
CONCLUSION: Our data demonstrated that advanced cancer patients with severe disease had increased healthcare utilization in all areas measured. Despite high utilization, outpatient support services used in a reactive manner were not effective in reducing ED or hospital visits.
There are more adults than children living with congenital heart disease (CHD) due to improvements in surgical and medical CHD management today. In 2011, though, fewer than 30% of adult CHD patients were following up with specialized providers. An ineffective transition from pediatric to adult-focused medical care can result in lapses in CHD medical care, patient noncompliance, and increased risk of late complications. Early involvement of a palliative care team offers development of autonomy, identification of potential barriers to care, and support for patient and family that may improve transition success and quality of life in CHD patients.
The prevalence of children on long-term ventilation (LTV) at home has increased in many countries. In Italy, there are 4.3/100,000 population younger than 18 years. Pediatric palliative care (PPC) network provides high-level care for these patients. In December 2003, in the northeast region of Italy, the regional authority promoted and developed a regional network for PPC, a regional network dedicated to the management of pediatric patients with life-limiting and life-threatening diseases. Characterization of LTV children population and description of care offered to them by a regional PPC network, based on the experience of the Veneto region were collected in a regional database. The regional database and evaluation of families' satisfaction, by means of a questionnaire, were longitudinally analyzed. We studied 56 children on LTV. The main involved diseases were neuromuscular diseases and myopathy. All patients had major comorbidities. Mean age was 4.5 years. The median age of starting ventilation was 3.9 years. The initial type of ventilation was invasive mechanical ventilation in 31 patients and noninvasive ventilation in 25 of them. The overall average frequency of hospitalizations for acute episodes was 0.7 admissions per year and the median duration of staying was 6 days. The median duration of staying in the intensive care unit (ICU) was significantly reduced after the opening of a residential solution (the pediatric hospice) (5 vs. 39 days). PPC network can offer global care to children on LTV. The availability of a residential structure into the PPC network seems to reduce the number and duration of hospital stays, especially in ICU, of this population, with likely cost savings. Further studies are necessary to confirm this hypothesis.
Palliative care, unlike hospice, can be utilized concurrently with disease-modifying or curative therapies. Some of the benefits of palliative care include improved quality of life, less end-of-life treatment, and decreased medical costs. Furthermore, palliative care can help guide treatment decisions to be in line with patients' physical, psychological, and spiritual needs. On the basis of these benefits, we advocate for palliative care involvement early in the course of advanced malignancy and other terminal diagnoses.
OBJECTIVES: To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration.
DESIGN: Cross-sectional observational study comparing ACO-attributed beneficiaries with propensity score-matched beneficiaries not attributed to an ACO.
SETTING: A total of 21 hospital referral regions (HRRs) in the United States.
PARTICIPANTS: Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013-2014.
MEASUREMENTS: Outcome measures were claims-based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics.
RESULTS: Compared with beneficiaries not in an ACO, ACO-attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0-4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = -1.7 percentage points; CI = -3.1 to -.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO-penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non-ACO patients in both medium and high ACO-penetration HRRs.
CONCLUSION: Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients.
CONTEXT: Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress.
OBJECTIVE: Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients.
METHODS: Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting.
RESULTS: Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress "some, most, or all of the time" when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient's course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late.
CONCLUSIONS: The majority of providers and nurses reported that comfort care was started too late in a patient's course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.