Early Care Planning Discussions Are Associated with Less Hospital Care at the End of Life in Veterans with Advanced Cancer (TH336-C)

Abstract

1.List four factors that are associated with less intensive care at the end of life among veterans.2.Describe two components of early care planning discussions relevant to less intensive care at the end of life. Early discussions about end-of-life (EOL) care preferences are recommended in advanced cancer. Evaluate associations between early discussions about care preferences and intensity of EOL care among veterans with advanced cancer. We studied decedents from the VA National Cancer Quality ASSIST study, which evaluated the quality of supportive care for veterans diagnosed with Stage IV colorectal, lung, or pancreatic cancer in 2008. We assessed the multivariate relationship between discussion of care preferences in the first month after diagnosis and validated indicators of EOL care intensity (hospital care, intensive interventions, and chemotherapy in the last month of life or no/late hospice use), controlling for patient factors. Of 665 decedents (34% colorectal, 35% lung, 31% pancreatic), 47% had an early discussion of patient preferences. Mean survival time was 8 months. Patients who had an early discussion were less likely to receive hospital care at the EOL (OR:0.67; P=0.025) than patients who did not, although patients who were co-pay exempt were almost twice as likely to receive hospital care (OR:1.86; P =0.001) than those not exempt. Other patient factors associated with lower intensity of care at EOL included older age (patients>75 years were less likely than younger patients to receive EOL chemotherapy [OR:0.46; P =0.029) or no/late hospice [OR:0.59; P=0.014]); cancer type (lung [OR:0.60; P=0.014] and pancreatic [OR: 0.45; P=0.000] cancer patients were less likely to receive no/late hospice than colorectal cancer patients); and longer survival time (less likely to receive acute care [OR:0.95; P=0.000], intensive interventions [OR:0.94; P=0.013] and no/late hospice [OR:0.95; P=0.000]). Early discussions are associated with less hospital care among veterans at EOL. Older age, longer survival time, and certain cancer types are associated with lower, and co-pay exempt status with higher, intensity of care at EOL.