Hospitalization burden and end-of-life (EOL) care in elderly patients with glioblastoma (GBM).

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 31-31
Author(s):  
Laura Donovan ◽  
Donna Buono ◽  
Melissa Kate Accordino ◽  
Jason Dennis Wright ◽  
Andrew B. Lassman ◽  
...  
Keyword(s):  
Socioeconomic Status ◽  
Palliative Care ◽  
Elderly Patients ◽  
Marital Status ◽  
End Of Life ◽  
Remaining Life ◽  
Care Services ◽  
Palliative Care Services ◽  
Race Ethnicity ◽  
Eol Care

31 Background: GBM is associated with a poor prognosis and early death in elderly patients. Prior studies have demonstrated a high burden of hospitalization in this population. We sought to evaluate and examine trends in hospitalizations and EOL care in GBM survivors. Methods: Using SEER-Medicare linked data, we performed a retrospective observational cohort study of patients aged ≥ 65 years diagnosed with GBM from 2005-2017 who lived at least 6 months from the time of diagnosis. Aggressive EOL care was defined as: chemotherapy or radiotherapy within 14 days of death (DOD), surgery within 30 DOD, > 1 emergency department visit, ≥ 1 hospitalization or intensive care unit admission within 30 DOD; in-hospital death; or hospice enrollment ≤ 3 DOD. We evaluated age, race, ethnicity, marital status, gender, socioeconomic status, comorbidities, prior treatment and percentage of time hospitalized. Multivariable logistic regression was performed to determine factors associated with aggressive end of life care. Results: Of 5827 patients, 2269 (38.9%) survived at least 6 months. Among these, 1106 (48.7%) survived 6-12 months, 558 (24.6%) survived 12-18 months, and 605 (26.7%) survived > 18 months. Patients who survived 6-12 months had the highest burden of hospitalization and spent a median of 10.6% of their remaining life in the hospital compared to those surviving 12-18 months (5.4%) and > 18 months (3%) (P < 0.001). 10.1% of the cohort had claims for palliative care services; 49.8% of initial palliative care consults occurred in the last 30 days of life. Hospice claims existed in 83% with a median length of stay 33 days (IQR 12, 79 days). 30.1% of subjects received aggressive EOL care. Receiving chemo at any time (OR 1.510, 95% CI 1.221-1.867) and spending ≥ 20% of life in the hospital after diagnosis (OR 3.331, 95% CI 2.567-4.324) were associated with aggressive EOL care. Women (OR 0.759, 95% CI 0.624-0.922), patients with higher socioeconomic status (OR 0.533, 95% CI 0.342-0.829), and those diagnosed ≥ age 80 (OR 0.723, 95% CI 0.528-0.991) were less likely to receive aggressive EOL care. Race, ethnicity, marital status, and extent of initial resection were not associated with aggressive EOL care. Conclusions: A minority of elderly patients with GBM in the SEER-Medicare database survived ≥ 6 months; hospitalizations were common and patients spent a significant proportion of their remaining life hospitalized. Although hospice utilization was high in this cohort, 30% of patients received aggressive EOL care. Despite the aggressive nature of GBM, few patients had palliative care consults during their illness. Increased utilization of palliative care services may help reduce hospitalization burden and aggressive EOL care in this population.

End-of-life cancer care: Health service delivery in the last 12 months of life in Calgary, Alberta, Canada.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 171-171
Author(s):  
Marc Kerba ◽  
Ayn Sinnarajah ◽  
M Sarah Rose ◽  
Lynn Nicholson ◽  
Barbara Wheler ◽  
...  
Keyword(s):  
Palliative Care ◽  
Service Delivery ◽  
End Of Life ◽  
Disease Duration ◽  
Multivariate Regression Analysis ◽  
Health Service Delivery ◽  
Care Services ◽  
Palliative Care Services ◽  
Eol Care ◽  
To Receive

171 Background: In Calgary, Alberta, the Calgary Zone Palliative Care Collaborative (CZPCC) undertook a study to examine the current state of cancer and palliative services and to recommend steps to address gaps in service delivery. We hypothesized that early access to palliative care services would reduce utilization of active cancer treatments and services for individuals nearing the end of life. Our study objectives were to determine the utilization and timing of acute, palliative and oncology-related services in Calgary. Methods: This retrospective study examined cancer registry and administrative data for patients > 18 years, who died in 2012. Measures of aggressive end of life care (EOL) were also collected. A combination of descriptive statistics, tests of association and multivariate regression analysis were conducted. Results: N = 1909 died of cancer in 2012: median age 73 years (IQR: 62-82 years) and median disease duration 364 days (IQR: 92-1114 days). 40.6% of patients received systemic treatment in last 12 months of life. 29.9% received radiotherapy and 13.0% received psychosocial/spiritual care. Palliative care contact was 80.7%, inclusive of 20.6% who had an intensive palliative care unit admission. 5.2% had EOL chemotherapy and 3.8% received EOL radiotherapy. Up to 10.4% of patients had one or more hospital admission. There was no significant effect of age on those who received aggressive EOL care. Men had an increased probability to receive aggressive EOL care (p = 0.015). Tumor group was also associated with receiving aggressive EOL (p < 0.001), with the highest utilization in Head and Neck and hematological malignancies. In patients with a disease duration of > 4 months those who received palliative care at least 2-3 months prior to death were less likely to receive aggressive EOL care (P < 0.001). Patients whose disease duration was < 1 month were less likely to receive aggressive EOL care if they received palliative care services (p = 0.02). Conclusions: The provision of palliative care services at the end of life is most needed among men and certain tumor groups who are the highest users of aggressive EOL care.

American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of Palliative Care Into Standard Oncology Care

2012 ◽  
Vol 30 (8) ◽  
pp. 880-887 ◽  
Author(s):  
Thomas J. Smith ◽  
Sarah Temin ◽  
Erin R. Alesi ◽  
Amy P. Abernethy ◽  
Tracy A. Balboni ◽  
...  
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
End Of Life ◽  
Clinical Oncology ◽  
Metastatic Cancer ◽  
Expert Consensus ◽  
Care Services ◽  
Palliative Care Services ◽  
Oncology Care ◽  
American Society

Purpose An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to ASCO's membership following publication or presentation of potentially practice-changing data from major studies. This PCO addresses the integration of palliative care services into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. Clinical Context Palliative care is frequently misconstrued as synonymous with end-of-life care. Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness. Although the use of hospice and other palliative care services at the end of life has increased, many patients are enrolled in hospice less than 3 weeks before their death, which limits the benefit they may gain from these services. By potentially improving quality of life (QOL), cost of care, and even survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Until recently, data from randomized controlled trials (RCTs) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care have not been available. Recent Data Seven published RCTs form the basis of this PCO. Provisional Clinical Opinion Based on strong evidence from a phase III RCT, patients with metastatic non–small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care—when combined with standard cancer care or as the main focus of care—leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care. While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving, no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. Therefore, it is the Panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. Strategies to optimize concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes (eg, QOL, survival, health care services utilization, and costs) and on society, should be an area of intense research. NOTE. ASCO's provisional clinical opinions (PCOs) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a PCO was submitted for publication. PCOs are not continually updated and may not reflect the most recent evidence. PCOs cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine the best course of treatment for the patient. Accordingly, adherence to any PCO is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO PCOs describe the use of procedures and therapies in clinical trials and cannot be assumed to apply to the use of these interventions in the context of clinical practice. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO's PCOs, or for any errors or omissions.

Chemotherapy at the end of life: Do we know when to stop?

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e24005-e24005
Author(s):  
Renana Barak ◽  
Einav Zagagi Yohay ◽  
Barliz Waissengrin ◽  
Ido Wolf
Keyword(s):  
End Of Life ◽  
Disease Duration ◽  
Performance Status ◽  
Poor Quality ◽  
Palliative Intent ◽  
Care Services ◽  
Palliative Care Services ◽  
Eol Care ◽  
Oncologic Treatment

e24005 Background: Aggressive end-of-life (EOL) care in cancer patients, especially the administration of chemotherapy, is considered a poor-quality measure, that may divert the treatment course from its' main palliative intent. Decisions taken at EOL are more than evidence-based and often rely on cultural and personal prospects. The universal and free Israeli health care system enables the administration of active treatment without financial or regulatory barriers, even at EOL. Two major advancements in recent years were the implementation of national at-home palliative care services and the approval of targeted and immunotherapies for advanced cancers. We hypothesized that these changes will reduce the use of chemotherapy at EOL. Methods: We sampled consecutive patients treated at a tertiary oncology center who died of advanced cancers between January 2019 to August 2020, and examined the administration of oncologic treatments near EOL. Results: A total of 294 patients were included. Their median age was 67 and 147 were men, 64% (189) of the patients received oncologic treatment during the last month before death, chemotherapy was administered in nearly two-thirds of the cases, 64% (121), followed by immunotherapy (21%, 40), targeted therapy (10%, 19) and a clinical trial (5%, 9). Neither age (P = 0.4), gender (P = 0.9), performance status (P = 0.8), disease duration (P = 0.5), and type of previous oncologic treatment (P = 0.3) were associated with aggressive EOL care. Conclusions: Our data demonstrate that in the absence of any regulatory or financial limitations, an aggressive EOL care may be administered to the majority of patients, regardless of age, performance status or disease duration. Despite increasing use of immunotherapy and targeted therapies and despite its’ toxicity profile and low beneficial effect at this stage, chemotherapy remained the most commonly used type of treatment. These data call for the implementation of educational measures and appropriate universal guidelines, aiming at improving quality of treatment at the EOL, focusing on quality of life rather than the elusive potential of extending life.

scholarly journals Whose Business is Dying? Death, the Home and Palliative Care

2011 ◽  
Vol 17 (1) ◽  
Author(s):  
John Rosenberg
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Health Care Services ◽  
Death Scene ◽  
Care Services ◽  
Life Issues ◽  
Palliative Care Services ◽  
End Of Life Issues ◽  
Dying At Home ◽  
Communal Responsibility

The process of dying at home brings the nexus between the paternalism of conventional palliative care and a social understanding of end of life care into sharp focus. Away from institutional places of care, issues of ownership, compliance and communal responsibility are heightened. At this interface, palliative care services are confronted with the irony of relinquishing their 'ownership' of dying whilst leading communities to reclaim their principal role in the business of dying. This benign – but enduring – paternalism remains a barrier to a paradigmatic shift towards a more complete understanding of the business of dying. Whilst nascent attempts to promote community engagement in end of life issues are evident in the interface between palliative care and public health, dying remains, for the most part, the remit of health care services. In this article, I contend that the business of dying is incompletely attended. This lack of attention will be partially redressed here by considering the home as a fitting death scene.

Impact of palliative care on end-of-life management of cancer patients dying in the hospital.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20613-e20613
Author(s):  
Syed Mustafa Karim ◽  
Jamal M Zekri ◽  
Ehab Mosaad Abdelghany ◽  
Azhar Rizvi ◽  
Aboelkhair Al-Gahmi ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Cancer Patients ◽  
Healthcare Providers ◽  
Time Of Death ◽  
Chi Square ◽  
Palliative Care Teams ◽  
Palliative Care Services ◽  
Chi Square Test ◽  
Eol Care

e20613 Background: A substantial number of cancer patients receive inpatient care at the end-of-life (EoL). Involvement of palliative care teams during the course of cancer treatment has been shown to improve quality of life (QoL) in cancer patients. In this study, we compare the EoL care of cancer patients dying in the hospital under medical oncology (MO) and palliative care (PC) services. Methods: A retrospective review of medical records of adult cancer patients who received chemotherapy during their illness and died in our hospital between January 2010 and January 2012 was conducted. The quality metrics measured as endpoints were: chemotherapy given within 21 days of death, death in the ICU, CPR at time of death, and time from last chemotherapy to death (TLCD). These endpoints were compared between patients who died under the MO service (cohort A) and those dying under PC service (cohort B). Chi-square test and T-test were used to compare the endpoints between the two cohorts. Results: Of the 106 cancer patients who died in the hospital, 40 and 66 were in cohorts A and B respectively. 30% of all patients were 65 years of age or older, and were equally distributed between the two cohorts. Patients in cohort A were more likely to receive chemotherapy within last 3 weeks of life (27.5% versus 7.5%, p=0.012, 95% CI 4.16-37.15), to have CPR at time of death (15% versus 0%, p=0.005, 95% CI 4.2-29.8) and to die in the ICU (52.5% versus 1.5%, p=<0.001, 95% CI 33.3-67.1) as compared to patients in cohort B. The average time from last chemotherapy to death was significantly longer (221 days) for cohort B patients as compared to cohort A patients (96 days), p=0.01. Patients in cohort A who had PC consultation during their hospitalization had no differences in the measured endpoints when compared to patients in cohort B. Conclusions: Cancer patients who die in the hospital while under MO service without PC involvement tend to have more aggressive EoL care. This may impact negatively on some QoL features. Early referral to palliative care services may facilitate better understanding and fulfillment of the needs of cancer patients and their caregivers by the healthcare-providers.

scholarly journals Billed Palliative Care Services and End-of-Life Care in Patients with Hematologic Malignancies

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 384-384
Author(s):  
Vinay B Rao ◽  
Emmanuelle Belanger ◽  
Pamela C Egan ◽  
Thomas W. LeBlanc ◽  
Adam J Olszewski
Keyword(s):  
Palliative Care ◽  
Board Of Directors ◽  
Research Funding ◽  
Hematologic Malignancies ◽  
Care Quality ◽  
Medicare Beneficiaries ◽  
Advisory Committees ◽  
Care Services ◽  
Palliative Care Services ◽  
Eol Care

Background: Patients with hematologic malignancies often receive aggressive care at the end of life (EOL), leading to lower quality of life. Access to early palliative care may improve EOL care outcomes, its benefits are less well established in hematologic malignancies than in solid tumors. We sought to describe the use of palliative care services among Medicare beneficiaries with hematologic malignancies, and associated EOL quality measures. Methods: Using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare registry, we studied fee-for-service Medicare beneficiaries diagnosed with acute or chronic leukemias, lymphomas, myeloma, myelodysplastic syndrome, or myeloproliferative neoplasms, who died in 2001-2015. We described trends in the use of billed palliative care services (BPCS, identified by codes in clinician encounter claims: ICD-9 V66.7 or ICD-10 Z51.5). Among patients surviving &gt;30 days from diagnosis, we compared baseline characteristics and EOL care quality metrics for patients with and without "early" BPCS (defined as services initiated &gt;30 days before death), as well as Medicare spending in the last 30 days of life. Multivariable models were fitted as appropriate according to outcome variable (robust Poisson, negative binomial, or log-gamma) and adjusting for hematologic malignancy histology, patients' age, sex, race, marital status, Medicaid co-insurance, comorbidity index and performance status indicator (calculated from claims within 1 year before death), and year of death. Results: Among the 139,191 decedents, median age at death was 82 years and 46.4% were women. The proportion with any BPCS was 5.2% overall during the study period, and it increased from 0.4% in 2001 to 13.3% in 2015 (Fig. A). Median time from the first BPCS encounter to death was 10 days (interquartile range, 3 to 39), and it increased from 6 days in 2001 to 12 days in 2015. Most (84.3%) BPCS encounters occurred during hospital admissions (Fig. B), and this proportion did not significantly change over time. Although the number of BPCS claims increased over time for any specialty, there was a relative increase in claims billed by nurse practitioners (from 7.9% in 2001/05, to 29.7% in 2011/15) or palliative care specialists (from 0% to 15.6%, respectively). Use of early BPCS remained rare, but increased from 0.2% in 2001 to 4.3% in 2015. Overall, early BPCS constituted 28.5% of all first BPCS. A relatively higher proportion of early BPCS occurred in the ambulatory setting (15.0%). In the comparative cohort of patients who survived &gt;30 days from diagnosis (N=120,741, Table), the use of early BPCS (1.7% overall) was more frequent in acute leukemia than in other histologies, adjusting for other factors. It was also significantly more frequent among Black patients, those with higher comorbidity indices or poor performance statuses, and those who received active chemotherapy at any point. Presence of early BPCS was associated with significantly improved EOL care quality metrics, including higher rates of hospice use, longer hospice length of stay, and lower use of aggressive measures, like repeated hospitalizations, admissions to the intensive care unit, and receipt of chemotherapy in the last 14 days of life (see Table). Early BPCS were also associated with significantly lower average Medicare spending in the last 30 days of life (marginal means $21,380 with and $23,651 without early BPCS, P&lt;.001). Conclusion: Use of BPCS among Medicare beneficiaries with hematologic malignancies has increased steeply in recent years, but most encounters still occur within days of death in the inpatient setting. This pattern potentially limits the benefits that could be achieved for patients and their caregivers with earlier institution of palliative care. Early BPCS are associated with better EOL care quality metrics similar to those observed in solid tumors, but causation remains uncertain in retrospective claims data, especially given known underutilization of palliative care billing codes in non-terminal patients. Our results support the need for prospective trials of early palliative care for patients with hematologic malignancies, and for research about the barriers to early access to palliative care that may be specific to this patient population. Disclosures LeBlanc: Pfizer Inc: Consultancy; Heron: Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; CareVive: Consultancy; Agios: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Medtronic: Membership on an entity's Board of Directors or advisory committees; Otsuka: Consultancy, Membership on an entity's Board of Directors or advisory committees; Helsinn: Consultancy; Astra Zeneca: Consultancy, Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Consultancy, Research Funding; American Cancer Society: Research Funding; Duke University: Research Funding; Jazz Pharmaceuticals: Research Funding; NINR/NIH: Research Funding; Flatiron: Consultancy; Celgene: Honoraria. Olszewski:Genentech: Research Funding; TG Therapeutics: Research Funding; Adaptive Biotechnologies: Research Funding; Spectrum Pharmaceuticals: Research Funding.

Effectiveness of palliative care services: A population-based study of end-of-life care for cancer patients

2018 ◽  
Vol 32 (8) ◽  
pp. 1344-1352 ◽  
Author(s):  
Rossana De Palma ◽  
Daniela Fortuna ◽  
Sarah E Hegarty ◽  
Daniel Z Louis ◽  
Rita Maria Melotti ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Cancer Patients ◽  
Conditional Logistic Regression ◽  
Emergency Department Visits ◽  
Administrative Databases ◽  
Hospital Death ◽  
Care Services ◽  
Palliative Care Services ◽  
The Impact

Background: Multiple studies demonstrate substantial utilization of acute hospital care and, potentially excessive, intensive medical and surgical treatments at the end-of-life. Aim: To evaluate the relationship between the use of home and facility-based hospice palliative care for patients dying with cancer and service utilization at the end of life. Design: Retrospective, population-level study using administrative databases. The effect of palliative care was analyzed between coarsened exact matched cohorts and evaluated through a conditional logistic regression model. Setting/participants: The study was conducted on the cohort of 34,357 patients, resident in Emilia-Romagna Region, Italy, admitted to hospital with a diagnosis of metastatic or poor-prognosis cancer during the 6 months before death between January 2013 and December 2015. Results: Patients who received palliative care experienced significantly lower rates of all indicators of aggressive care such as hospital admission (odds ratio (OR) = 0.05, 95% confidence interval (CI): 0.04–0.06), emergency department visits (OR = 0.23, 95% CI: 0.21–0.25), intensive care unit stays (OR = 0.29, 95% CI: 0.26–0.32), major operating room procedures (OR = 0.22, 95% CI: 0.21–0.24), and lower in-hospital death (OR = 0.11, 95% CI: 0.10–0.11). This cohort had significantly higher rates of opiate prescriptions (OR = 1.27, 95% CI: 1.21–1.33) ( p < 0.01 for all comparisons). Conclusion: Use of palliative care at the end of life for cancer patients is associated with a reduction of the use of high-cost, intensive services. Future research is necessary to evaluate the impact of increasing use of palliative care services on other health outcomes. Administrative databases linked at the patient level are a useful data source for assessment of care at the end of life.

Policy in palliative care

2015 ◽  
Author(s):  
David C. Currow ◽  
Stein Kaasa
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Health Care Providers ◽  
World Health ◽  
Care Providers ◽  
Care Services ◽  
Palliative Care Services ◽  
Organization Policy ◽  
Health Organization ◽  
Hospice Palliative Care

Hospice and palliative care services have developed in very different ways around the world. Most have been built on the momentum of visionary clinicians and funders who have responded to perceived needs from health-care providers, patients, families, and communities rather than in response to well-formed national policies with an adequately funded planning and development phase. This chapter describes the work that is being done at pan-national, national, and sub-national levels to create effective policies that can further the key work of hospice/palliative care, often after a large number of apparently unconnected local services have been well established. The chapter highlights that there are particular challenges in forming public policy on hospice/palliative care, especially the end-of-life component, and notes the importance of ‘patients’ voices’-the voice of the community which helps to inform health policies including end-of-life care. The chapter ends by describing a variety of country-specific and World Health Organization policy documents and legislation.

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