Aggressive care at the end of life: A study of practice based factors in patients with stage IV cancer.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 80-80
Author(s):  
Mohammad Omar Atiq ◽  
Rahul Ravilla ◽  
Ajay Kumar ◽  
Sajjad Haider ◽  
Ji-Ling Tang ◽  
...  
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
End Of Life ◽  
Cancer Patients ◽  
Stage Iv ◽  
Goals Of Care ◽  
Significant Difference ◽  
Aggressive Care ◽  
Stage Iv Cancer ◽  
End Stage

80 Background: Numerous studies established that early utilization of palliative care-hospice services are beneficial to cancer patients. To reduce the incidence of aggressive care in terminal cancer patients, we conducted a quality improvement study to identify pertinent risk factors and develop interventions. Methods: Through chart review, we retrospectively identified patients with stage IV cancer that were followed by oncology clinic and were admitted to the University Hospital between 8/1/2015-10/31/15. For those patients who died during the last hospitalization or were discharged to hospice care, we obtained demographic, cancer related and practice related variables listed in Table. We used Mann Whitney U test and multivariable regression to find effects of factors related to length of stay (LOS) and cost of stay (COS). Results: Length of stay was significantly prolonged in those receiving chemotherapy within the past month (6 vs 3 p=0.035). Multivariate analyses found that patients with goals of care documented in the clinic had lower COS by 36.7% and LOS by 46.7%. On average, an ICU stay resulted in COS 2.2 times higher. No significant difference was seen in LOS based on a documented palliative care clinic visit or presence of an advanced directive. Conclusions: We identified practice based factors that need improvement including earlier goals of care conversations and less chemotherapy at the end of life. Identifying end stage patients in earlier admissions, collaborating with palliative care, and adding goals of care documentation to clinic note templates, are all interventions we are studying to improve care for end stage cancer patients. [Table: see text]

Influence of timing of goals of care discussion on hospitalization outcomes in metastatic cancer patients.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18183-e18183
Author(s):  
Oluwadunni Emiloju ◽  
Djeneba Audrey Djibo ◽  
Jean G Ford
Keyword(s):  
Palliative Care ◽  
Critical Care ◽  
Length Of Stay ◽  
Cancer Patients ◽  
Hospital Readmission ◽  
Metastatic Cancer ◽  
Hospital Readmissions ◽  
Stage Iv ◽  
Continuous Variables ◽  
Goals Of Care

e18183 Background: Cancer patients often require acute hospitalizations, many of which are unplanned. These hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals of care (GOC) discussions be initiated early for metastatic cancers. We hypothesize that discussing GOC during hospitalization will help reduce readmissions and improve patient satisfaction, by helping to ensure that patients receive goal-congruent care. We aim to examine the association between the timing of GOC discussion and the patient's length of stay and the time to hospital readmission. Methods: We conducted a retrospective review of medical records of patients with stage IV solid tumors who were hospitalized acutely between August 2017 and July 2018 (N = 241). We assessed demographics, clinical information, timing of GOC discussion, use of palliative care services and hospital readmissions within 90 days. Chi-square tests were used to identify independent associations with having a GOC discussion; and anova was used for continuous variables. We used logistic regression to examine the association with a hospital readmission within 90 days, controlling for potential confounders. Results: The subjects were 26-92 years old and 40.6% were female. Only 43% (n = 106) of patients had a GOC discussion. Age, gender, tumor site, and presenting complaint were not independently associated with having a GOC discussion (p > 0.05). Overall, 34.4% (n = 83) had a palliative care encounter. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (p < 0.05). Length of stay was positively correlated with having a GOC discussion. Thirty-seven percent (n = 91) had unplanned hospital readmission within 90 days. Having any GOC discussion reduced the odds of an unplanned hospital readmission within 90 days by 75% [OR = 0.25, 95% confidence interval (CI) 0.14-0.45]. Conclusions: Among hospitalized patients with stage IV cancer, performing an early GOC discussion is associated with better hospitalization outcomes. It is therefore important to perform GOC discussion early when such patients are acutely hospitalized.

Influence of timing of goals of care discussion on hospitalization outcomes in metastatic cancer patients.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 219-219
Author(s):  
Oluwadunni Emiloju ◽  
Jean G Ford ◽  
Djeneba Audrey Djibo
Keyword(s):  
Palliative Care ◽  
Critical Care ◽  
Length Of Stay ◽  
Cancer Patients ◽  
Hospital Readmission ◽  
Metastatic Cancer ◽  
Hospital Readmissions ◽  
Stage Iv ◽  
Continuous Variables ◽  
Goals Of Care

219 Background: Cancer patients often require acute hospitalizations, and these hospitalizations have been shown to increase in frequency near the end of life. The American College of Physicians recommends that goals of care (GOC) discussions be initiated early for metastatic cancers. Discussing GOC during hospitalization can help reduce readmissions and improve patient satisfaction, by helping to ensure that patients receive goal-congruent care. We aim to examine the association between the timing of GOC discussion and the patient's length of stay and the time to hospital readmission. Methods: We conducted a retrospective review of medical records of patients with stage IV solid tumors who were hospitalized acutely between August 2017 and July 2018. We assessed demographics, timing of GOC discussion, use of palliative care services and hospital readmissions within 90 days. Chi-square tests were used to identify independent associations with having a GOC discussion; and anova was used for continuous variables. We used logistic regression to examine the association with a hospital readmission within 90 days, controlling for potential confounders. Results: The subjects were 26-92 years old and 40.6% were female. Only 46% (n = 112) of patients had a GOC discussion. Age, tumor site, and presenting complaint were not independently associated with having a GOC discussion (p > 0.05). Overall, 34% (n = 82) had a palliative care encounter. Having a palliative care consult and being admitted to critical care were independently associated with having a GOC discussion. Early timing of GOC discussion was inversely associated with admission to critical care units (p < 0.05). Length of stay was positively correlated with having a GOC discussion. Thirty-eight percent (n = 92) had unplanned hospital readmission within 90 days. Having any GOC discussion reduced the odds of an unplanned hospital readmission within 90 days by 79% [OR = 0.21, 95% confidence interval 0.12-0.37]. Conclusions: Among hospitalized patients with stage IV cancer, performing an early GOC discussion is associated with better hospitalization outcomes. It is therefore important to perform GOC discussion early when such patients are acutely hospitalized.

scholarly journals Perubahan Status Koagulasi Pasien Kanker Padat Pasca Kemoterapi di Indonesia: Sebuah Studi Prospektif

2020 ◽  
Vol 7 (1) ◽  
pp. 2
Author(s):  
Noorwati Sutandyo ◽  
Lyana Setiawan
Keyword(s):  
Cancer Patients ◽  
Prospective Cohort ◽  
Stage Iv ◽  
Stage Iii ◽  
Solid Cancer ◽  
Significant Difference ◽  
Before And After ◽  
Coagulation Status ◽  
Stage Iv Cancer ◽  
D Dimer

Pendahuluan. Hiperkoagulasi merupakan faktor yang mendasari tingginya mortalitas akibat kejadian tromboemboli vena pada pasien kanker. Kemoterapi merupakan salah satu faktor yang diduga berkontribusi terhadap status hiperkoagulasi pada pasien kanker. Studi ini bertujuan untuk mengevaluasi perubahan status koagulasi yang ditandai dengan kadar D-dimer pada pasien kanker yang menjalani kemoterapi.Metode. Studi ini merupakan studi kohort prospektif di Pusat Kanker Nasional Indonesia yang melibatkan pasien kanker yang sudah terkonfirmasi melalui pemeriksaan histopatologi, dan memulai kemoterapi pada periode Mei hingga Juli 2018. Perubahan status koagulasi dinilai melalui kadar D-dimer plasma. Kadar D-dimer diukur sebelum dan 7 hari setelah kemoterapi. Analisis statistik menggunakan uji t berpasangan untuk menilai kemaknaan perubahan kadar D-dimer plasma sebelum dan setelah kemoterapi.Hasil. Sejumlah 89 pasien memenuhi kriteria inklusi, yang mana 74,2% adalah perempuan dan hampir separuh dari keseluruhan subjek terdiagnosis kanker payudara (44,9%). Mayoritas subjek (69,6%) terdiagnosis pada stadium III atau IV. Sejumlah 12,4% dari subjek mendapatkan kemoterapi berbasis cisplatin. Terdapat perbedaan yang bermakna antara kadar D-dimer sebelum dan setelah kemoterapi (p = 0,05). Studi ini juga menemukan perbedaan bermakna kadar D-dimer sebelum dan sesudah kemoterapi pada pasien kanker stadium III (t(35) = 2,48, p = 0,02) dan stadium IV (t(25) = 2,14, p = 0,04). Tidak terdapat perbedaan bermakna antara kadar D-dimer sebelum dan setelah kemoterapi pada pasien stadium I dan II. Analisis lanjutan berdasarkan kelompok kemoterapi menunjukkan bahwa terdapat perubahan kadar D-dimer yang bermakna pada kelompok yang mendapatkan kemoterapi cisplatin (t(10) = 2,31, p = 0,04), namun tidak pada kelompok yang mendapat kemoterapi non-cisplatin (t(77) = 1,50, p = 0,14).Simpulan. Terdapat perbedaan bermakna status koagulasi yang ditandai dengan kadar D-dimer 7 hari pasca mendapatkan kemoterapi, khususnya pada pasien kanker stadium III atau IV dan mendapatkan kemoterapi berbasis cisplatin. Kata Kunci: Cisplatin, kanker, kemoterapi, status koagulasiChange of Coagulation Status in Solid Cancer Patients Undergoing Chemotherapy in Indonesia: A Prospective Cohort StudyIntroduction. Cancer-associated hypercoagulability was an underlying factor of high mortality of cancer due to venous thromboembolism. Chemotherapy is proposed as one of the contributing factors of the hypercoagulable state. We aim to evaluate the change of coagulation status, which was marked by D-dimer level, in cancer patients receiving chemotherapy.Methods. This is a prospective cohort study in Indonesian national cancer center which involves all adult histologically-confirmed-cancer patients who started chemotherapy between May and July 2018. The coagulation status is assessed by plasma of D-dimer level. We measured D-dimer before chemotherapy and one week after chemotherapy. Paired t-test was performed to assess the significant difference in D-dimer levels before and after chemotherapy.Results. A total of 89 patients fulfilled the eligibility criteria, of whom 74.2% were female and almost half of total subjects (44.9%) were breast cancer patients. Majority of subjects (69.6%) were stage III or stage IV cancer. There were 12.4% of subjects received cisplatin-based chemotherapy. There was a marginally significant difference in plasma level of D-dimers before and after chemotherapy (p = 0.05). We also found significant differences between D-dimer level before and after chemotherapy in stage III patients (t(35) = 2.48, p = 0.02) and stage IV patients (t(25) = 2.14, p = 0.04). There was no significant difference between D-dimer level before and after chemotherapy in stage I and stage II patients. Subgroup analyses based on chemotherapy agents showed that there was significant D-dimer change in cisplatin-based chemotherapy subjects (t(10) = 2.31, p = 0.04), but not in non-cisplatin-based chemotherapy subjects (t(77) = 1,50, p = 0.14).Conclusion. Compared to before chemotherapy, there is a significant difference of coagulation status marked by plasma D-dimer level one week after chemotherapy, particularly in patients with stage III or stage IV cancer and in patients receiving cisplatin-based chemotherapy.

Chemotherapy use at the end of life in Brazil.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e24003-e24003
Author(s):  
Munir Murad Junior ◽  
Thiago Henrique Mascarenhas Nébias ◽  
Marcos Antonio da Cunha Santos ◽  
Mariangela Cherchiglia
Keyword(s):  
Palliative Care ◽  
Cancer Treatment ◽  
End Of Life ◽  
Cancer Patients ◽  
Stage Iv ◽  
Breast Cancers ◽  
Early Palliative Care ◽  
Study Population ◽  
One Year

e24003 Background: Chemotherapy in the last days of life is not associated with a survival benefit, and recent data suggest it may cause harm by decreasing quality of life and increasing costs. Both ESMO and ASCO have published position statements encouraging discussions about the appropriate cessation of chemotherapy. End-of-life chemotherapy rates vary worldwide but in summary, up to a fifth of cancer patients are treated with chemotherapy in the last month of life with no clear benefits. The aim of this study is to describe the rate of chemotherapy use in the last month of life in patients who are candidates for palliative care in Brazil. Methods: It is a prospective non-concurrent cohort carried out from a database developed through probabilistic and deterministic linkage of data from information systems of the Brazilian Public Health System. The study population is composed of all patients who started cancer treatment between 2009 and 2014 and who was hospitalized at least 1 time after starting treatment. To address the indication for palliative care, patients whose death occurred within one year after the first hospitalization were selected. Results: A total of 299,202 patients started cancer treatment in that period and 62,249 died 1year after hospitalization. Among the deceased patients, the median age was 62 years, 50.9% of them were in stage IV and 34.1% in stage III and 46% lived in the southeastern region of the country. The most common cancers were lung (n = 17805; 28.6%) colorectal (n = 12273; 19.7%) and gastric (n = 10248; 16.5%). The average number of hospitalizations was 2.7 and 89% of these patients required emergency hospitalization. About half (45,4%; n=28,250) of the patients underwent chemotherapy at the last 30 days of life. The rates of use of chemotherapy in the last month was 44% for lung cancer, 74,4% for colon, 50.2% for gastric and 51.8% breast cancers. Conclusions: Despite international recommendations on the use of chemotherapy at the end of life, this seems to be a common practice unfortunately. Measures to implement early palliative care should be a priority for the care of cancer patients in Brazil.

OP456 Encouraging Shared Decision-Making Of Goals Of Care Discussions In Lung Cancer Patients Using A Smartphone Application

2021 ◽  
Vol 37 (S1) ◽  
pp. 17-17
Author(s):  
Amanda Lovato ◽  
Nisha Almeida
Keyword(s):  
Lung Cancer ◽  
Palliative Care ◽  
Focus Groups ◽  
End Of Life ◽  
Cancer Patients ◽  
Smartphone Application ◽  
Quality Improvement Initiative ◽  
Care Hospital ◽  
Goals Of Care ◽  
Lung Cancer Patients

IntroductionAn important reason for receiving non-beneficial treatment at end-of life is the lack of timely discussions on goals of care and end-of-life preferences. A recent randomized clinical trial demonstrated that patients primed with a questionnaire on their end-of-life preferences were more likely to initiate such conversations with their doctors. Our objective is to integrate the questionnaire into a smartphone application to facilitate early goals of care discussions. To achieve this goal, we first plan to undertake a feasibility study to understand stakeholder preferences.MethodsAs part of a quality improvement initiative at our Canadian quaternary-care hospital, we conducted focus groups with oncology and palliative care physicians and patients to understand barriers to early conversations on end-of-life preferences, and to assess feasibility of using smartphone technology in facilitating these conversations. The app would integrate a questionnaire to patients and send prompts to physicians on patient readiness and timing of conversations.ResultsWe conducted separate focus groups with lung cancer patients (n = 6) and clinicians in oncology (n = 6) and palliative care (n = 6). Clinical teams expressed enthusiasm about early conversations but raised several barriers including system (lack of electronic documentation and access to data; multiple physicians), clinician (lack of time) and patient (stigma associated with end-of-life) barriers. Clinicians agreed that an app could overcome some of these barriers such as access to patient and electronic data by making patients the repository of all their data and empowering them to initiate discussions. However, they raised concerns about universal accessibility of such technology, especially among the elderly. Patient focus groups will take place in March 2021 and inform us on feasibility in this population.ConclusionsThere is a consensus among physicians at our hospital that early end-of-life conversations have the potential to mitigate adverse events and that use of a smart phone app could facilitate such conversations.

Advance Directive and Do-Not-Resuscitate Status among Advanced Cancer Patients with Acute Care Surgical Consultation

2018 ◽  
Vol 84 (10) ◽  
pp. 1565-1569
Author(s):  
Lobsang Marcia ◽  
Zane W. Ashman ◽  
Eric B. Pillado ◽  
Dennis Y. Kim ◽  
David S. Plurad
Keyword(s):  
Length Of Stay ◽  
Cancer Patients ◽  
Acute Care ◽  
Metastatic Cancer ◽  
Stage Iv ◽  
Acute Care Surgery ◽  
Do Not Resuscitate ◽  
Stage Iv Cancer ◽  
Care Surgery ◽  
Dnr Orders

Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients ( P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.

Bowel obstruction with stage IV cancer: The benefit of introduction of formal palliative care service.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20573-e20573
Author(s):  
Moshim Kukar ◽  
Adrienne Groman ◽  
Yashodhara K. Satchidanand ◽  
Amy I. Alvarez-Perez ◽  
Kelli B. Dunn ◽  
...  
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
Bowel Obstruction ◽  
Care Service ◽  
Palliative Care Service ◽  
Stage Iv ◽  
Palliative Care Team ◽  
Care Team ◽  
Comorbid Conditions ◽  
Stage Iv Cancer

e20573 Background: Patients with stage IV cancer and bowel obstruction (BO) present a complicated management problem. The aim of this study was to evaluate the role of introduction of an organized palliative care service in the management of this complex disease process. Methods: We conducted a retrospective analysis of all patients admitted to the Roswell Park Cancer Institute with stage IV cancer and BO after the institution of formal palliative care service (PS) in 2009. This cohort was compared to a group prior to 2009 (No Palliative care service Group; NPS). The two groups were compared with respect to demographics, comorbid conditions, DNR status, laboratory parameters, medical, surgical management, length of stay and disposition status. Results: 28 patients were identified in PS group as compared to 40 patients in NPS group. The 2 groups were similar in terms of age, gender, race, comorbid conditions, primary site of cancer, chemotherapy, radiation therapy and weight loss. There was a statistically significant difference in the medication regimen provided, as those who had palliative care consults were more likely to receive alternative medications to standard anti-emetics (Table). The palliative care team followed 19/28 patients and 14/19 patients showed improvement in their symptoms (nausea, pain control) in initial 24 hours after the palliative care consult. 50 % ( n=14) of patients in PS group had a formal DNR order in place as compared to 15.4% in NPS group (p<0.001). In 9/14 patients the first discussion regarding DNR was held by palliative care team. A significantly higher percentage of patients were discharged to the hospice care in PS group (42.9% vs. 7.5%, p =0.006). Conclusions: BO in patients with stage IV cancer often poses a dilemma in the choice of surgery versus medical management. Palliative care consults, early in the hospitalization, may help improve symptom management, end of life discussions, better psychosocial support, discharge placements and will eventually translate to shorter length of stay. [Table: see text]

The sooner the better: Analysis of proactive palliative medicine consultation in the medical intensive care unit amongst patients with stage IV malignancy.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 78-78
Author(s):  
Shanna R Levine ◽  
Earle I Bridget ◽  
Wendy S.A. Edwards
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Palliative Medicine ◽  
Symptom Relief ◽  
Stage Iv ◽  
Active Stage ◽  
Trigger Tool ◽  
Goals Of Care ◽  
Rehabilitation Facility

78 Background: Palliative care has been shown to improve quality of life and prolong median survival in patients with advanced cancer. Sadly, patients are still suffering at the end of their lives perhaps secondary to aggressive hospital care. ICU use in the last month of life increased from 24.3% to 29.2% over the last study decade. Our objective was to evaluate and quantify outcomes, including survival, of patients with active stage IV malignancy admitted to an urban university affiliated hospital MICU who had a palliative medicine consult. Methods: A retrospective chart review of patients from 04/2013 - 04/2014 admitted to the MICU with active stage IV malignancy identified via a validated proactive case finding trigger tool. The trigger was based on eight criteria, one of which being active stage IV malignancy. The MICU census was reviewed biweekly. Data collected included pain and symptom relief, clarification of goals of care, length of stay, and disposition (hospice, rehabilitation facility, home and death). Results: Four hundred sixty eight patients were assessed. One hundred and twenty two patients met 1 of the 8 criteria, and 24 patients met the inclusion criteria for review. Three patients were not seen due to attending and/or family preference. Thirty eight percent of patients had improved symptoms and management control, 42% had clarification of goals of care and medically appropriate decision making, and 42% experienced psychosocial spiritual counseling. Eight patients died during their hospital stay, 4 were transferred to inpatient hospice facilities, 3 to rehabilitation facility, 2 went home and the remainder was “other”. The average length of stay of patients seen by palliative care was 20 days compared to 31 days for patients not seen by the palliative team. Conclusions: Nearly 40% of patients with active stage IV malignancy admitted to the MICU died during their hospital stay. We believe this study illuminates the futility of ICU care in this patient population. Consultation from the palliative medicine team using a proactive trigger tool can be beneficial to allow for better symptom control, clarification of goals and psychosocial counseling.

Utilization of care at the end of life in Medicare decedents with advanced cancer.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 22-22
Author(s):  
Audrey S. Wallace ◽  
Courtney Williams ◽  
Maria Pisu ◽  
Debra Parker Oliver ◽  
Gabrielle Betty Rocque
Keyword(s):  
End Of Life ◽  
Stage Iv ◽  
Medicare Beneficiaries ◽  
Hospice Patients ◽  
Hospice Referral ◽  
Ed Visits ◽  
Aggressive Care ◽  
Southeast Us ◽  
Stage Iv Cancer ◽  
Late Referral

22 Background: Despite increasing evidence supporting minimization of aggressive care at the end of life, little literature exists reporting timing of chemotherapy and radiation in relation to hospice referral. Methods: Deceased Medicare beneficiaries age ≥65 years with stage IV cancer at 12 sites in 5 southeast US states were identified from 2012-2015. All utilization of radiation, chemotherapy, hospice, hospitalizations, and emergency department [ED] visits were abstracted and tabulated from Medicare claims during the last 6 months of life. Results: Among 3516 deceased patients, median age at time of metastatic disease was 73 years (IQR 68-79). Most patients were white (81%), male (55%), with two or more comorbidities (54%). The most common primary cancer sites were lung (38%), gastrointestinal (27%), and genitourinary (10%). In the last 6 months of life, 65% and 66% of patients visited the ED or were hospitalized; 11% received radiation and 28% received chemotherapy. Median days from last course of treatment to death for patients with chemotherapy (n = 978) was 45 days (IQR 23-83) and with radiation (n = 380) was 52 days (IQR 19-100). After completion of radiation, 54% of patients continued to receive systemic therapy. In subset analysis of patients with a hospice referral after final delivery of radiation and/or chemotherapy (n = 768), there was persistent late referral to hospice. Patients referred to hospice within 0-7 days of completing radiation or chemotherapy had similar median length of time on hospice when compared to those referred to hospice between 91-180 days after treatment (median 14 [IQR 4-35] vs. median 18 [IQR 8-43] days). Conclusions: In decedents with poor performing cancer histologies, low utilization of hospice and high rates of ED visits and hospitalization remain. Late referral to hospice persisted irrespective of last course of radiation or chemotherapy timing. High utilization of hospitalization and emergency visits at EOL may be ameliorated by earlier hospice referral.

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