Neoplastic Diseases Medical Care in Advanced Cancer

8 Background: ASCO recommends that early palliative care (PC) be offered alongside standard cancer care for patients with metastatic cancer and/or high symptom burden. There is limited data about how the timing of PC affects the quality, intensity, and cost of care at the end of life for patients with advanced cancer. Methods: We analyzed administrative and billing data to assess patterns of healthcare utilization for a cohort of patients at an academic comprehensive cancer center who died from cancer between Jan 1, 2010 and May 31, 2012. We examined the associations of early PC (>90 days prior to death) versus late PC (<90 days prior to death) with QOPI, NQF, and other established quality metrics and direct cost of medical care in last 6 months of life. Results: Among 978 decedents who received treatment at the cancer center, only 298 (30%) had specialty PC referrals. Of these patients, 94 (9.6% of decedents, 31.5% of referrals) had early PC while 204 (21% of decedents, 68.5% of referrals) had late PC. Patients who received early PC had a lower rate of inpatient admissions in the last month of life (33% vs. 66%, p=0.002), lower rates of ICU stay in last month of life (5% vs. 20%, p=0.0005), fewer ED visits in last month (34% vs. 54%, p=0.0002), fewer instances of hospice length of service <3 days (7% vs. 20%, p=0.0001), and a lower rate of inpatient death (15% vs. 34%, p=0.0001). Most patients (84%) who received early PC were seen as outpatients, while late PC was mostly delivered in the hospital (82.4%). Of the late PC cohort, only 52 (25.4%) were ever seen in the outpatient PC clinic, but 170 (83%) had at least one oncology office visit 91-180 days prior to death. The direct cost of inpatient medical care in the last 6 months of life for patients with early PC was reduced when compared to patients who had late PC ($19k vs. $25.7k), while the direct cost of outpatient care was higher in the early PC compared to late PC population ($13k vs. $11.5k). Conclusions: Early PC is associated with less intensive medical care and improved quality outcomes at the EOL for patients with advanced cancer. Early PC results in a significant inpatient cost savings with a modest increase in outpatient costs. Early PC is likely best delivered in the outpatient setting.

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Impact of Immigrant Status on Aggressive Medical Care Counter to Patients' Values Near Death among Advanced Cancer Patients

Journal of Palliative Medicine ◽

10.1089/jpm.2018.0244 ◽

2019 ◽

Vol 22 (1) ◽

pp. 34-40 ◽

Cited By ~ 2

Author(s):

Megan Johnson Shen ◽

Holly G. Prigerson ◽

Ana I. Tergas ◽

Paul K. Maciejewski

Keyword(s):

Medical Care ◽

Cancer Patients ◽

Advanced Cancer ◽

Immigrant Status ◽

Advanced Cancer Patients

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Provision of Spiritual Support to Patients With Advanced Cancer by Religious Communities and Associations With Medical Care at the End of Life

JAMA Internal Medicine ◽

10.1001/jamainternmed.2013.903 ◽

2013 ◽

Vol 173 (12) ◽

pp. 1109 ◽

Cited By ~ 156

Author(s):

Tracy A. Balboni ◽

Michael Balboni ◽

Andrea C. Enzinger ◽

Kathleen Gallivan ◽

M. Elizabeth Paulk ◽

...

Keyword(s):

Medical Care ◽

End Of Life ◽

Advanced Cancer ◽

Religious Communities ◽

Spiritual Support

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Personalized end-of-life care: Associations between patient preferences and treatment intensity near death

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.6516 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. 6516-6516 ◽

Cited By ~ 1

Author(s):

A. A. Wright ◽

J. W. Mack ◽

E. D. Trice ◽

T. A. Balboni ◽

S. D. Block ◽

...

Keyword(s):

Medical Care ◽

End Of Life ◽

Advanced Cancer ◽

Treatment Center ◽

Treatment Intensity ◽

Cancer Type ◽

Do Not Resuscitate ◽

Icu Admission ◽

Eol Care ◽

Prospective Longitudinal

6516 Background: Medical treatment at the end-of-life (EOL) should be responsive to patient values, but research shows it may instead reflect the regional supply of health services and/or physician practice patterns. We sought to determine whether patients' preferences are associated with EOL medical care and place of death. Methods: Coping with Cancer is an NCI/NIMH-funded, multi-site prospective, longitudinal cohort study of patients with advanced cancer, conducted from September 2002-February 2008. Analyses were based upon 317 deceased patients interviewed at baseline and followed until death, a median of 4.4 months later. EOL care was obtained from chart review, and regressed on patients' baseline preferences for life-extending therapy. Analyses were adjusted for significant confounds; i.e., socio-demographics, cancer type, patient denial, EOL discussion, do-not resuscitate (DNR) order, and treatment center. A sub-analysis examined EOL care within three different medical centers to determine whether patients' preferences and treatment intensity varied by region/practice type. Results: 90 of 317 patients (28.4%) reported a desire to receive life-extending therapy at baseline. Patients' preferences did not differ by proximity to death or performance status, but patients who preferred life-extending therapy had higher rates of denial (75.0% vs. 55.6%, p = 0.002) and were less likely to report having an EOL conversation (24.4% vs. 48.9%, p = 0.0002) or a DNR order (24.4% vs. 48.9%, p < 0.0001). These patients were more likely to undergo ICU admission (AOR 4.6, 95% CI 1.9–11.1) and ventilation (AOR 3.0, 95% CI 1.2–7.3), and die in an ICU (AOR 6.7, 95% CI 2.4–18.7) instead of at home (AOR 0.6, 95% CI 0.3–0.9). A sub-analysis of patients treated at Yale, Parkland, and New Hampshire Oncology-Hematology confirmed that patients' preference for life-extending treatment was associated with higher rates of ICU admission in all three centers. Conclusions: Advanced cancer patients' treatment preferences may play a more important role in determining the intensity of medical care at the EOL than previously recognized. Future research should determine whether these preferences are informed and thus reflect patients' true values for EOL care. No significant financial relationships to disclose.

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Advancing Research on Spiritual Influences at the End of Life Comment on “Provision of Spiritual Support to Patients With Advanced Cancer by Religious Communities and Associations With Medical Care at the End of Life”

JAMA Internal Medicine ◽

10.1001/jamainternmed.2013.922 ◽

2013 ◽

Vol 173 (12) ◽

pp. 1117 ◽

Cited By ~ 2

Author(s):

Christopher G. Ellison ◽

Maureen R. Benjamins

Keyword(s):

Medical Care ◽

End Of Life ◽

Advanced Cancer ◽

Religious Communities ◽

Spiritual Support

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Application of data mining in the provision of in-home medical care for patients with advanced cancer

Translational Cancer Research ◽

10.21037/tcr-21-896 ◽

2021 ◽

Vol 0 (0) ◽

pp. 0-0

Author(s):

Chao Yang ◽

Ruihua Yu ◽

Hui Ji ◽

Haosheng Jiang ◽

Wanli Yang ◽

...

Keyword(s):

Data Mining ◽

Medical Care ◽

Advanced Cancer ◽

Home Medical Care

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Medical care and emotional distress associated with advanced cancer patients' end-of-life discussions with their physicians

Journal of Clinical Oncology ◽

10.1200/jco.2008.26.15_suppl.6505 ◽

2008 ◽

Vol 26 (15_suppl) ◽

pp. 6505-6505 ◽

Cited By ~ 6

Author(s):

A. A. Wright ◽

A. Ray ◽

B. Zhang ◽

J. W. Mack ◽

S. L. Mitchell ◽

...

Keyword(s):

Medical Care ◽

End Of Life ◽

Cancer Patients ◽

Advanced Cancer ◽

Emotional Distress ◽

Advanced Cancer Patients

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Tailoring end-of-life discussions to advanced cancer patients’ state of grief

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.9500 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. 9500-9500

Author(s):

H. G. Prigerson ◽

A. A. Wright ◽

S. D. Block ◽

P. K. Maciejewski

Keyword(s):

Medical Care ◽

End Of Life ◽

Advanced Cancer ◽

Cancer Diagnosis ◽

Chart Review ◽

Advanced Cancer Patients ◽

Coping With Cancer ◽

Eol Care ◽

Prospective Longitudinal ◽

Prospective Longitudinal Cohort

9500 Background: Prior research has shown end-of-life (EOL) discussions are not associated with significant psychological distress, but are associated with earlier referrals to hospice and lower rates of intensive care. Nevertheless, associations between EOL discussions and care received may vary depending on patients’ state of grief over their cancer diagnosis. The aim of this study was to determine how Kubler-Ross’ proposed 5 states of grief –numbness, anger, bargaining, depression, and acceptance –modify the effects of EOL discussions on EOL care received. We hypothesized that the early grief state of numbness would interfere with patients’ processing of an EOL discussion, thereby, reducing its association with care received. Methods: Coping with Cancer is an NCI/NIMH-funded, multi-site prospective, longitudinal cohort study of patients with advanced cancer, conducted from September 2002-February 2008. Analyses were based upon 316 deceased patients who were interviewed at baseline and followed until death 4.4 months later. Patients were assessed at baseline on 5 grief states in response to their cancer diagnosis (i.e., numbness, anger, bargaining, depression, and acceptance) and whether an EOL discussion with their physician had occurred. Information on medical care received in the last week of life was obtained from chart review, and regressed on the interaction between each of the 5 grief states and the patient's report of an EOL discussion. Results: Of the 5 grief states, only numbness significantly moderated the effect of EOL discussions on medical care received. For patients with higher than average numbness (i.e., ≥ 1 on the 0–4 numbness score continuum), the effect of EOL discussions on ventilation or resuscitation in the last week of life was significantly reduced by a factor of 10 [OR=9.96, 95% CI (1.21–82.2)]; the effect of EOL discussions on death in the ICU was significantly reduced by a factor of three [OR=2.98, 95% CI (1.01–8.78)]. Conclusions: Associations between EOL discussions and care received are much reduced among patients who are high on numbness (i.e., those who have not resolved the 1st grief state). Physicians should consider their patients’ grief state (i.e., numbness) when deciding whether to engage in EOL discussions. No significant financial relationships to disclose.

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