End-of-life (EOL) care in medical oncology fellows' clinics.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 75-75 ◽  
Author(s):  
Yang Liu ◽  
Chethan Ramamurthy ◽  
Fern Anari ◽  
Asya Varshavsky ◽  
James Martin ◽  
...  
Keyword(s):  
End Of Life ◽  
Medical Oncology ◽  
Critical Time ◽  
Fellowship Training ◽  
Care Utilization ◽  
Advanced Directives ◽  
Exact Test ◽  
Code Status ◽  
Eol Care ◽  
Communication Methods

75 Background: Medical oncology fellowship training presents a critical time for developing skills necessary for discussing end of life (EOL) care preferences with patients and delivering EOL care. There is little data exploring the delivery of EOL care by fellows in practice. We describe our fellows’ experience and identify areas to improve delivery of EOL care and communication. Methods: We retrospectively reviewed electronic medical records (EMR) of patients at our center with advanced (metastatic or recurrent) solid tumors who received care in fellows’ clinics and died between 7/1/2016 and 6/7/2017. We used Fisher’s exact test to determine associations between variables. Results: We included 103 patients from 46 distinct fellow clinics covered by 16 fellows. 54 (52%) were male; median age was 70 (37-94) years. 42 (40%) had a gastrointestinal malignancy, 31 (30%) had lung cancer. Median duration of advanced cancer was 12 (0.5-120) months. Patients received a median of 2 (1-10) lines of chemotherapy. 10 (10%) received chemotherapy within 14 days of death. 10 (10%) used outpatient palliative care (PC). 48 (47%) had EOL/hospice discussions in the outpatient clinic, while 10 (10%) had code status documented in a clinic encounter, and 20 (19%) had a copy of an advanced directive in the EMR. Median time from EOL discussion to death was 30 days (4-171). 69 (67%) enrolled in hospice and median length of stay on hospice was 18 days (1-142). 58 (56%) were hospitalized and 13 (13%) admitted to the ICU within 30 days of death. Of patients not enrolled in hospice, 8 (8%) died at home without hospice, 23 (22%) died in a hospital or ICU, 3 (3%) died in other or unknown places. Patients who had EOL discussions in clinic were more likely to enter hospice (p = .006) and less likely to be hospitalized (p = 0.016) within 30 days of death. Conclusions: Fellows at our center have significant exposure to outpatient EOL discussions and delivery of EOL care. EOL discussions in clinic were associated with decreased rates of health care utilization within 30 days of death. There were low rates of outpatient code status discussions and documentation of advanced directives, and few patients received outpatient PC, which represent potential areas to enhance fellow training and improve patient EOL care.

scholarly journals HOW MEDICAL EDUCATION ALLEVIATED ETHICAL DILEMMAS IN RESIDENTS DURING END-OF-LIFE FAMILY MEETINGS IN THE SOUTH TEXAS

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S295-S295
Author(s):  
Jessica G Martin ◽  
Andrya Rivera-Burciaga ◽  
Cesar Gutierrez ◽  
Andrew Dentino
Keyword(s):  
End Of Life ◽  
Planning Process ◽  
Extended Family ◽  
Role Playing ◽  
Interactive Methods ◽  
Advanced Directives ◽  
Family Unit ◽  
Family Meetings ◽  
Eol Care ◽  
Hispanic Family

Abstract The UTRGV DHR Internal Medicine Program conducted a study addressing end of life (EOL) care focused on our Hispanic community in regards to communication and trust between patients, caregivers, and healthcare providers. Our residents train at a community hospital which cares for an 89% Hispanic population of 1.2 million, spanning over 4 counties of the Rio Grande Valley. Trainees are often involved in family meetings while treating hospitalized, terminally ill patients. Although family meetings are a standard approach in palliative care, Hispanic family meetings tend to occur more often and with a larger, extended family unit. Our intent was to educate our residents to initiate conversations about EOL care choices promoting delivery of patient-centered, family oriented care utilizing culturally appropriate information regarding EOL issues. Baseline surveys were provided to all 39 trainees which assessed anxiety, incompetence, and communication skills in delivering bad news during family meetings. An advanced care planning process was implemented over 3 months with a goal to engage patients in EOL conversations, initiation, and completion of advanced directives. Residents received weekly training on interactive methods and ethical concepts including group discussions, role-playing, and demonstrations which were culturally and linguistically appropriate. We found that physician competence in conducting Hispanic family meetings is vital. Residents completed a post-training survey resulting in 100% improved attitudes and behaviors such as confidence, satisfaction, caring and empathy. They felt more comfortable and prepared to speak to a larger family unit who was likely to ask a lot of questions and request multiple meetings.

Palliative care training: A national survey of U.S. hematology/oncology fellows.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 28-28
Author(s):  
Brendan F. Curley ◽  
Roby Antony Thomas ◽  
Sijin Wen ◽  
Jianjun Zhang ◽  
Jame Abraham ◽  
...  
Keyword(s):  
Palliative Care ◽  
Pearson Correlation ◽  
Statistical Significance ◽  
Fellowship Training ◽  
Categorical Variables ◽  
Exact Test ◽  
Dying Patients ◽  
Oncology Practice ◽  
Eol Care

28 Background: The American Society of Clinical Oncology (ASCO) has recommended integration of palliative care into oncology practice at the time of diagnosis of advanced cancer. The attitudes, knowledge, and skills of Hematology/Oncology fellows in palliative medicine to implement this recommendation have not been assessed. Methods: In 2013 we surveyed current US Hematology/Oncology fellows to assess their attitudes and the quality of teaching in palliative care received during fellowship and their perceived preparedness to care for patients at End of Life (EOL). Trainees at all US programs were surveyed via Research Electronic Data Capture. The survey was IRB approved, anonymous and voluntary. Results: 176 surveys were collected. Statistical analysis was performed with t-test for numeric and Fisher’s exact test for categorical variables. 98% of respondents felt that providing care for dying patients was important. 99% indicated that physicians have a responsibility to help patients at EOL. Fellows felt their overall training in fellowship was superior to their quality of training (p<0.0001) or teaching (p <0.0001) on EOL. Pearson correlation showed that those with training in palliative care felt more prepared caring for patients at EOL (p <0.0001). Fellows who had training in palliative care during fellowship (45.4% of those surveyed) felt they had better teaching on managing a patient at EOL than those who did not (p<0.0001). There was no statistical significance noted with self-identified roles of spirituality or religion in attitudes, knowledge, or skills. 64% reported having conducted over ten family meetings regarding EOL. Only 18.9% were supervised (p<0.0001) and only 13.1% were given feedback more than ten times (p<0.0001). 89.7% of fellows surveyed stated they have disagreed with treatment without palliative care on at least one occasion. 40% of respondents did not know how to respond to a request to stop chemotherapy. Conclusions: Hematology/Oncology fellows believe that EOL care is important. Education about EOL is not at the same level of their overall fellowship training despite the recognition of the benefit of palliative care in Oncology. Educational initiatives need to be introduced to improve training on EOL care.

Hepatocellular carcinoma and end-of-life care.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 278-278
Author(s):  
Natasha Hunter ◽  
Jamie Erin Potosek ◽  
Rebecca A. Miksad
Keyword(s):  
Hepatocellular Carcinoma ◽  
Liver Disease ◽  
End Of Life ◽  
Cancer Patients ◽  
Tertiary Care ◽  
Patient Characteristics ◽  
Care Hospital ◽  
Similar Time ◽  
Code Status ◽  
Eol Care

278 Background: Patients with hepatocellular carcinoma (HCC) usually present with incurable tumors and advanced underlying liver disease. Although guidelines exist to assess the quality of end of life (EOL) care for cancer patients, little is known about EOL care for HCC patients. Due to the complexity and multidisciplinary nature of the disease, we hypothesized that EOL care for HCC patients differs from that delivered to other cancer patients and may be heterogenous based on patient characteristics and primary clinician specialty. Methods: We assessed EOL HCC care through medical chart review of 188 consecutive HCC patients treated at an academic tertiary care hospital who died between 2007 and 2013. Based on available data, EOL care and documentation was assessed per published guidelines. Patient, HCC and liver disease characteristics, cancer treatments, symptom burden, and EOL care and documentation was compared by provider specialty. The odds of receiving aggressive EOL care by provider specialty, patient characteristics, and documentation measures were calculated. Using data from the Dartmouth Atlas Project, we compared results with EOL data for cancer patients overall at our institution and nationally during a similar time frame. Results: Fewer HCC patients enrolled in hospice compared with cancer patients overall at our institution, and nationally (36%, 49% and 55%, respectively). In addition, HCC patients spent fewer days on hospice, spent more time in the hospital, and experienced more (and longer) intensive care unit admissions. Compared to those primarily cared for by other specialties, HCC patients seen by an oncologist were more likely to have goals of care (GOC) documentation and to enroll in hospice. Patients never seen by an oncologist were more likely to have a psychiatric illness. English as a non-primary language and code status documentation were among factors associated with more aggressive EOL care. Conclusions: At our institution, EOL care for HCC patients is more aggressive compared to cancer patients overall and nationally. The subset of HCC patients seen by oncology were more likely to meet EOL quality guidelines (GOC documentation and hospice enrollment). A better understanding of EOL practices for HCC may impact multidisciplinary care.

Health care utilization and costs at end of life among patients with leukemia or lymphoma in a regional cancer registry-insurance claims linked database.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 184-184
Author(s):  
Cara L McDermott ◽  
Catherine R. Fedorenko ◽  
Karma L. Kreizenbeck ◽  
Ted Conklin ◽  
Bruce Smith ◽  
...  
Keyword(s):  
End Of Life ◽  
High Intensity ◽  
Hematologic Malignancies ◽  
Care Utilization ◽  
Future Research ◽  
Intensity Of Care ◽  
Western Washington ◽  
The Difference ◽  
Eol Care ◽  
Out Of Pocket Costs

184 Background: End-of-life (EOL) care for persons with hematologic malignancies is variable and often involves high-intensity services at death approaches, which may not reflect patient or family preferences. We characterized healthcare utilization and associated costs in the last 30 days of life among subjects with leukemia or lymphoma to better understand patterns of care in this population. Methods: We linked enrollment and claims records from two regional commercial insurers to Surveillance, Epidemiology, and End Results (SEER) records for patients diagnosed with leukemia or lymphoma in Western Washington state between January 1, 2007 and December 31, 2015. We developed algorithms to characterize EOL care and calculate costs from both the payer and patient perspective for the last 30 days of life. Costs are derived from paid claims for inpatient, outpatient, and pharmacy utilization. Patient out-of-pocket costs are calculated as the difference between allowed and paid claim amounts. Results: See Table. Conclusions: In this analysis, a majority of subjects usedat least one form of high intensity care in the last 30 days of life, and average out-of-pocket costs were considerable. Future research will focus on developing interventions to assess patient and family preferences for intensity of care to better inform the provision of high-value care in this population. [Table: see text]

Evaluating end-of-life (EOL) care at the University of Rochester Medical Center (URMC) using quality oncology practice initiative (QOPI) metrics.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 12-12
Author(s):  
Titas Banerjee ◽  
Jason Harold Mendler ◽  
Nabeel Badri ◽  
Dwight Hettler ◽  
Julie Ann Berkhof ◽  
...  
Keyword(s):  
End Of Life ◽  
Medical Center ◽  
Statistical Significance ◽  
Inpatient Mortality ◽  
Exact Test ◽  
Number Of Patients ◽  
Advanced Malignancies ◽  
Oncology Practice ◽  
The University ◽  
Eol Care

12 Background: Inpatient mortality, defined as death within 30 days of an acute hospital admission, is often used as a quality benchmark for healthcare institutions and is an important metric for evaluating quality of care of patients with advanced malignancies. In this study we aimed to utilize QOPI performance data to identify areas of weakness in our practice that may contribute to inpatient mortality. Methods: We analyzed 11 EOL measures within the QOPI database which we collected between 2015 and 2018. These included all EOL measures related to hospice enrollment (measure IDs 42-47), chemotherapy administered within the last 2 weeks of life (ID 48), percentage of patients who died from cancer with at least one emergency department (ED) visit in the last 30 days of life (ID 49ed), and the percentage of patients who died from cancer admitted to the Intensive Care Unit (ICU) in the last 30 days of life (ID 49icu). Our rate was calculated for each measure and compared against QOPI aggregate data. We used a fisher’s exact test to determine statistical significance for each metric. Results: The number of patients from our institution included in each analysis ranged from 27 to 46. Compared to our peers, patients treated at our institution were more likely to visit an ED in the last 30 days of life (68% vs. 32%; P < 0.0001), more likely to be admitted to the ICU in the last 30 days of life (29% vs. 9%; P = 0.0003), and more likely to be enrolled on hospice within the last 7 days of death (63% vs. 32%; P = 0.001). Conclusions: Analysis of QOPI EOL performance scores identified several metrics that may contribute to inpatient mortality at URMC. Ongoing participation in QOPI with a focus on EOL metrics will strengthen this analysis. We plan to use this data to guide quality improvement initiatives aimed at reducing impatient mortality and improving end of life care at our institution.

scholarly journals Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error

2019 ◽  
Vol 14 (11) ◽  
pp. 716-718 ◽  
Author(s):  
Barry Meisenberg ◽  
Sohail Zaidi ◽  
Lori Franks ◽  
David Moller ◽  
David Mooradian
Keyword(s):  
United States ◽  
Medical Error ◽  
The United States ◽  
Appropriate Use ◽  
Advanced Directives ◽  
Code Status ◽  
Professional Societies ◽  
Open Discussion ◽  
Eol Care ◽  
System Errors

The United States health system has been criticized for its overuse of aggressive and medically ineffective life-sustaining therapies (LST).1 Some professional societies have elevated dialog about end-of-life (EOL) care to a quality measure,2 expecting that more open discussion will achieve more “goal-concordant care”3 and appropriate use of LST. However, even when Advanced Directives (AD) or Physician Orders for Life-Sustaining Therapy (POLST) have been created, their directions are not always followed in the hospital. This perspective discusses how preventable errors allow for use of LST even when patients designated it as unwanted. Two cases, chosen from several similar ones, are highlighted, demonstrating both human and system errors.

Patterns of palliative care utilization and end-of-life care in adult patients with cancer who died as inpatients at Mayo Clinic.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 60-60
Author(s):  
Collin Thomas Zimmerman ◽  
Shivani S. Shinde ◽  
Pashtoon Murtaza Kasi ◽  
Mark Robert Litzow ◽  
Jeanne M. Huddleston
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Mayo Clinic ◽  
Small Sample ◽  
Index Admission ◽  
Care Utilization ◽  
P Value ◽  
Advanced Malignancy ◽  
Code Status ◽  
Number Of Patients

60 Background: A significant number of patients with advanced cancer die in the hospital. Examination of patterns of care and palliative care (PC) involvement may identify opportunities for process of care improvements for this vulnerable population. Methods: Patients were identified using the institutional mortality review system registry (Mayo Clinic hospitals from July, 2013-June, 2014). Within this group, patients with a diagnosis of terminal malignancy were identified by chart review and ICD-9 codes. Patient demographics, clinical characteristics, and use of PC resources were characterized in the last 60 days of life. Results: There were 159 of 924 decedents identified whose primary cause of death was advanced malignancy (Table). Ninety-two patients (57%) had PC consultation during the index admission preceding death, while 31 (19%) patients had seen PC as an outpatient or inpatient prior to index admission. Lack of inpatient PC consultation at index admission was associated with hematologic malignancy (p < 0.001), full code status at death (p 0.009), shorter median time between change of code status to DNR and death (13 vs 67 hrs, p < 0.001), death in the ICU (58% vs 31%, p < 0.001), and presence of code blue (22% vs 5%, p-value = 0.003). Patients who received a PC consultation were less likely to have chemotherapy within 14 days of death (15% vs 37%, p-value = 0.001), and had a median composite aggressive end of life score (6 factor composite score based on utilization in last 30 days of life, higher score indicating more aggressive care) of 3 vs 4 (p 0.002). Conclusions: Inpatient PC consultation for cancer patients who die in the hospital is associated with less aggressive cancer care at end of life. The single-institution patient population and small sample size are the limitations of our study. [Table: see text]

End-of-life care for glioblastoma multiforme patients at an academic institution.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 202-202
Author(s):  
Kamini Kuchinad ◽  
Roy E Strowd ◽  
Anne Evans ◽  
Louise Knight ◽  
W. Anthony Riley ◽  
...  
Keyword(s):  
Length Of Stay ◽  
End Of Life ◽  
End Of Life Care ◽  
Hospice Care ◽  
Secondary Analysis ◽  
The United States ◽  
Care Utilization ◽  
Johns Hopkins Hospital ◽  
Life Care ◽  
Code Status

202 Background: End of life care for glioblastoma patients has not been studied in the United States. We studied 100 patients with GBM to examine use of advance directives (AD), symptom assessments, hospitalizations, chemotherapy use, and hospice use. Methods: A single center retrospective cohort study of adult patients actively treated for GBM at Johns Hopkins Hospital from 2009-2014. 100 patients were randomly chosen from the group of 317 GBM patients. Information included documentation of AD, code status, hospitalizations, chemotherapy use, code status and symptom assessments. A secondary analysis of all JHH GBM patients who received hospice care at Gilchrist Hospice during this time period was analyzed using the electronic medical record and hospice records to evaluate date of referral to hospice, length of stay in hospice and location of death. Results: Of 100 patients, 76 were referred to hospice. Only 40% of individuals had documentation of code status and only 17% had any documentation of ADs in the outpatient chart. Formal symptom, spiritual, or psychosocial assessments were seldom documented in the outpatient record. Only 17% used chemotherapy in their last month of life. 37% were hospitalized in the last month of life for an average of 9 days. Of the Gilchrist Hospice patients, the median length of stay in hospice was 21 days and 64% of these patients died in their residence with hospice services. Conclusions: More formalized palliative care utilization and structure could improve end of life care for GBM patients, especially in the use of ADs; formal symptom, spiritual, and psychosocial assessments; and earlier use of hospice to prevent end of life hospitalizations.

Process measures of palliative and end-of-life care among young adults who died from cancer.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 54-54
Author(s):  
Hanneke Poort ◽  
Sophia Zupanc ◽  
Alexi A. Wright ◽  
Charlotta Lindvall
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
End Of Life Care ◽  
Cancer Center ◽  
Life Care ◽  
Process Measures ◽  
Goals Of Care ◽  
Code Status ◽  
Essential Components ◽  
Eol Care

54 Background: Timely delivery of palliative and end-of-life care (EOL) are essential components of high-quality cancer care. To date, however, few studies have examined process measures for EOL care in young adult (YA; ages 18-35 years) cancer decedents. Methods: We conducted a retrospective study using medical records of YA decedents who received cancer treatment at an academic cancer center between Jan. 1, 2012 and June 13, 2018. We used natural language processing (NLP) with validated key words to identify documentation of four process measures – palliative care involvement, and discussions of goals of care, code status, and hospice – from documented clinical encounters in the medical record within 6 months of death. Results: During this period 146/2,878 (5.1%) YA patients had a recorded death date and a first note at least 31 days prior to death. In this decedent cohort, the mean age was 28.2 years (SD=4.4) and 58.9% were men. The most common diagnoses were brain cancer (33.6%), sarcoma (19.9%), and breast cancer (12.3%). The 146 patients accrued 26,441 clinical notes during the last 6 months of life (median=116.5 notes, IQR 37.0-222.0). Using NLP, we identified that 68.5% of the 146 YAs had at least one process measure documented in the last 6 months of life, including: 54.1% palliative care involvement; 56.8% discussions of goals of care; 47.3% discussions of code status; and 51.4% discussions of hospice. On average, palliative care was documented 7.5 times (range 0-75); goals of care 6.1 times (range 0-43), code status 1.9 times (range 0-12), and hospice 8.1 times (range 0-67). Late documentation of process measures (defined as first recorded within 30 days of death) included: hospice (45.3%), code status (30.3%), palliative care (20.8%), and goals of care (9.6%). Notably, in 31.5% of YAs, we did not detect documentation of any process measures prior to death. Conclusions: In this cohort of YA cancer decedents, nearly one-third of YAs did not have documentation of any process measures, highlighting the importance of efforts to improve EOL care communication with this young population.

Variation in the intensity of end-of-life care, hospice enrollment, and the cost of care by cancer site.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11539-11539
Author(s):  
Shitanshu Uppal ◽  
Versha Pleasant ◽  
Sarah Bell ◽  
R. Kevin Reynolds ◽  
Laurel Rice ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
End Of Life ◽  
Hospice Care ◽  
Cost Of Care ◽  
Cancer Site ◽  
Care Utilization ◽  
Median Cost ◽  
Multiple Cancer ◽  
The Cost ◽  
Eol Care

11539 Background: To compare end-of-life (EOL) care intensity across multiple cancer sites and its impact on the cost of care during the last 30-days of life. Methods: Cross-sectional retrospective study using Surveillance, Epidemiology, and End Results Program (SEER)-Medicare linked database from 2008-2013. Utilization of the following in the EOL period (last 30 days of life prior to death) was examined: 2 or more visits to the Emergency Department (ED), hospitalizations, receipt of any life-extending procedures, admission to intensive care unit, any hospice use, hospice used ≤3 days, death in hospital, or receipt of chemotherapy (last 14 days). We tallied the claims made during the EOL period for each patient. Median expenditures during the EOL period were tabulated by cancer site and stratified by receipt of hospice care. Results: EOL care utilization varied widely between cancer sites. The rates of any hospice utilization were the highest for breast cancer (48.2%) compared to ovarian (17.4%) (p < 0.001). Chemotherapy during the last two weeks of life was the highest for ovarian cancer (1.7%) and the lowest for colorectal cancer (0.5%). The median cost of care during the EOL period for patients who received hospice care was $7,547.84 (Interquartile range [IQR] $5,422-$17,293) compared to $17,179 (IQR $10,323 - $30,824) for those never received hospice care (p < .0001). There was no significant variation in median cost by cancer site for those who received hospice services (range $7,317 - $9,816). However, the cost of care varied for those who did not receive hospice care. Median costs for this subgroup was the lowest for pancreatic cancer ($14,635) and the highest for colorectal cancer ($24,324) (p < 0.001). Conclusions: Despite increasing acceptance of palliative care services and hospice in cancer care, there continues to be intensive and costly care administered during the EOL period. These costs vary considerably across cancer sites when patients do not receive hospice care, but costs are relatively similar when patient are enrolled in hospice Further research to investigate the causes of this variation should be undertaken to design interventions aimed at improving timely hospice enrollment at the EOL and reducing costly care in the EOL period.

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