Nursing and interdisciplinary interventions to support people with advanced cancer at the end of life in emergency departments: A systematic review.

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

PC-FACS

219 The Recognition of Hospice-Eligible Patients in the Emergency Department: A Missed Opportunity

Although much younger than the traditional oncology specialties, the palliative medicine discipline has blossomed to fill the notable void between the delivery of aggressive anticancer therapies and the patient experience of disease and its treatments. Although initial studies of palliative care (PC) interventions yielded mixed results, more recent randomized trials have shown improved mood, quality of life, and even improved survival with early PC consultation. These favorable results have been so consistent and marked that the American Society of Clinical Oncology (ASCO) has issued a clinical opinion supporting the integration of PC with conventional oncology treatment, and as part of the Choosing Wisely Campaign, the American Society for Radiation Oncology (ASTRO) has urged early PC referral in the context of noncurative radiotherapy. Additional benefits from PC intervention include the opportunity to reduce the frequency, intensity, and therefore cost of medical interventions at the end of life. Although the discipline centers on improving the well-being of patients and their caregivers, these economic benefits may be meaningful, reducing the total cost per patient on the order of thousands of dollars. Despite the stress of an acute illness, inpatient admissions can be an opportune time to initiate PC consultation: at this juncture, patients are often critically ill and may intuitively appreciate the gravity of their diagnosis, multidisciplinary consultation can be performed in one setting, and from an economic perspective, patient decision making can have marked implications for ensuing costs. When to initiate PC consultation over the course of an admission is an open question, however, and from a practical perspective, determining the optimal time for intervention may help programs orient their services. In the article that accompanies this editorial, May et al asked whether time to PC consultation influenced the potential cost savings of the intervention. The authors analyzed hospital cost data from a large, prospective, observational trial (the Palliative Care for Cancer, or PC4C trial) that was designed to study patient-reported outcomes (eg, pain intensity, satisfaction), process measures (eg, symptom assessment), and utilization measures, including cost. Patients with advanced cancer who were admitted to one of five hospitals with high-quality PC programs were eligible for enrollment, with a standardized PC consultation as the intervention. However, patients were included in the study even if they did not receive PC services. Thus, it is critical to recognize that the PC4C study was not a randomized trial; instead, the study was planned a priori to use propensity-based methods to compare PC consultation with usual care (UC), with the goal of using this statistical methodology to create pseudorandomized cohorts for comparisons. The majority of the data from this trial has not yet been reported, and the article by May et al describes the first key findings from the study. The authors performed cost comparisons by creating a series of PC versus UC cohorts among patients who survived the admission, each defined by the maximum time to PC consultation (any time, within 2, 6, 10, and 20 days). Because of the prospective nature of the data collection, each of the two groups was robustly matched on many important baseline variables, including the results of symptomassessment instruments. The key result was that early but not late PC consultation was associated with significant cost savings versus UC. There were reductions in total costs of approximately $2,300 and $1,300 with PC consultation within 2 and 6 days, respectively, but not when PC was applied 10 days or longer from admission; in fact, when comparing all patients receiving PC with all patients receiving UC, there was no significant difference in cost. Importantly, although laboratory costs were reduced whenever PC consultation was performed, intensive care unit and pharmacy costs were lowered only with the earliest consultations, suggesting that the avoidance of these aggressive interventions was the most influential driver of the cost savings; indeed, intensive care unit costs savings were more than triple the savings from the next largest contributor (pharmacy). The authors intentionally did not control for length of stay in their main analysis, assuming that shorter hospital admissions may be on the causal pathway between early PC intervention and lower expenditure. The average length of stay was significantly shorter by 1 day with the earliest consultations, supporting the contention that reduced admission length may also contribute to cost savings, together with a reduction in the intensity of care. This analysis builds on previous retrospective studies that have also shown that earlier inpatient consultation leads to greater cost savings, and on the basis of these results, one may argue that the PC intervention must be performed within 48 hours to achieve an economic benefit. However, there is an unavoidable collinearity between accrued hospital costs and time to PC consultation; the later the consultation, the more time available for the patient to undergo costly services before the intervention. It is therefore not necessarily surprising that the total impact of PC intervention on cost was mitigated as the time to consultation grew longer. Even still, it may be premature to dismiss the potential cost savings of later PC consultation. First, there is the challenge of drawing meaningful conclusions from the small JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 33 NUMBER 25 SEPTEMBER 1 2015

Using the Evidence for Palliative Care to Improve Outcomes for Patients With Heart Failure.

The Pediatric Quality of Life and Evaluation of Symptoms Technology Response to Pediatric Oncology Symptom Experience (PQ-Response) intervention aims to integrate specialized pediatric palliative care into the routine care of children, adolescents, and young adults (AYAs) with advanced cancer. To evaluate whether PQ-Response, compared to usual care, improves patient's health related quality of life (HRQoL) and symptom burden (aim 1), parent psychological distress and symptom-related stress (aim 2), and family and symptom treatment activation (aim 3). Multisite, randomized (1:1), controlled, un-blinded, effectiveness trial comparing PediQUEST Response (intervention) vs usual cancer care (control). Five US large, tertiary level pediatric cancer centers. Children (≥2 years old)/AYAs who receive care at any of the participating sites because of advanced cancer or any progressive/recurrent solid or brain tumor and are palliative care "naïve." Target: 200 enrolled patient-parent dyads (minimum goal: 136 dyads randomized, N = 68/arm). PediQUEST Response: combines patient-mediated activation (weekly feedback of patient- and parent-reported symptoms and HRQoL to families and providers using the PediQUEST web system) with integration of the palliative care team. Usual Cancer Care: participants receive usual care, which can include palliative care consultation, and use PediQUEST web to answer surveys, with no feedback. Following enrollment, patients (if ≥5 years) and one parent receive weekly PediQUEST-Surveys assessing HRQoL (Pediatric Quality of Life Inventory 4.0) and symptom burden (PediQUEST-Memorial Symptom Assessment Scale). After a 2-week run-in period, dyads who answer ≥2 PediQUEST surveys per participant (responders), are randomized (concealed allocation) and followed up for 16-weeks. Parents answer six additional surveys (parent outcomes). Primary: mean patient HRQoL score over 16-weeks as reported by a) the parent; and b) the patient if ≥5 years-old. Secondary: patient's symptom burden; parent's anxiety, depressive symptoms, symptom-related stress; family activation; and symptom treatment activation. ClinicalTrials.gov (NCT03408314) 1/24/18. https://clinicaltrials.gov/ct2/show/NCT03408314.

The delivery of palliative care is not standard of care within most emergency departments (EDs). To compare quality of life, depression, health care utilization, and survival in ED patients with advanced cancer randomized to ED-initiated palliative care consultation vs care as usual. A single-blind, randomized clinical trial of ED-initiated palliative care consultation for patients with advanced cancer vs usual care took place from June 2011 to April 2014 at an urban, academic ED at a quaternary care referral center. Adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by palliative care, spoke English or Spanish, and presented to the ED met eligibility criteria; 136 of 298 eligible patients were approached and enrolled in the ED and randomized via balanced block randomization. Intervention participants received a comprehensive palliative care consultation by the inpatient team, including an assessment of symptoms, spiritual and/or social needs, and goals of care. The primary outcome was quality of life as measured by the change in Functional Assessment of Cancer Therapy-General Measure (FACT-G) score at 12 weeks. Secondary outcomes included major depressive disorder as measured by the Patient Health Questionnaire-9, health care utilization at 180 days, and survival at 1 year. A total of 136 participants were enrolled, and 69 allocated to palliative care (mean [SD], 55.1 [13.1] years) and 67 were randomized to usual care (mean [SD], 57.8 [14.7] years). Quality of life, as measured by a change in FACT-G score from enrollment to 12 weeks, was significantly higher in patients randomized to the intervention group, who demonstrated a mean (SD) increase of 5.91 (16.65) points compared with 1.08 (16.00) in controls (P = .03 using the nonparametric Wilcoxon test). Median estimates of survival were longer in the intervention group than the control group: 289 (95% CI, 128-453) days vs 132 (95% CI, 80-302) days, although this did not reach statistical significance (P = .20). There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice. Emergency department-initiated palliative care consultation in advanced cancer improves quality of life in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study. clinicaltrials.gov Identifier: NCT01358110.

Characteristics of Peri-Transplant Palliative Supportive Care Consultation Among Older Allogeneic Hematopoietic Cell Transplant Recipients

9518 Background: Quality indicators have been developed to avoid overly aggressive care in patients with advanced cancer. Specialized palliative care (PC) may reduce overly aggressive care in patients with advanced pancreatic cancer. Our objective was to examine the impact of the intensity of specialized PC (defined as a physician consultation focusing on PC needs, lasting at least 40 minutes) on (a) use of chemotherapy within 14 days of death; (b) more than one emergency department (ED) visit; (c) more than one hospitalization; and (d) at least one intensive care unit (ICU) admission, all within 30 days of death. Methods: A retrospective population-based cohort study using linked administrative databases in Ontario, Canada was conducted with patients diagnosed with advanced pancreatic cancer from Jan 1 2005 to Dec 31 2010. Multivariable logistic regression analyses were performed with the above quality indicators as the outcomes of interest and the intensity of PC visits as the exposure, adjusting for other variables (age, sex, comorbidity, rurality, and health region). Intensity of PC was defined in both absolute numbers (ie 0, 1, 2, 3+ visits) and rate of visits per month. Results: Of 6076 patients with advanced pancreatic cancer, 5381 had died at last followup. 2816 (52%) received a PC consultation, 218 (4%) received chemotherapy near death, 234 (4%) patients went to the ICU near death, 993 (18%) had multiple ED visits near death, and 447 (8%) had multiple hospitalizations near death. 2565 (48%) had 0 PC visits, 513 (10%) had 1, 555 (10%) had 2, and 1748 (32%) had 3 or more. In multivariable analyses, having had one PC consultation was associated with a lower odds of ICU admission near death (odds ratio (OR) 0.25; 95% CI 0.13-0.46), multiple ED visits near death (OR 0.44; 95% CI 0.33-0.58), and multiple hospitalizations near death (OR 0.47; 95% CI 0.33-0.69). Two PC visits were associated with a lower OR for chemotherapy near death (OR 0.26; 95% CI 0.14-0.51). Using the monthly PC visit rate, a higher rate was associated with less aggressive care for each outcome. Conclusions: In patients with advanced pancreatic cancer, more intensive PC involvement is associated with less frequent overly aggressive care.

The period after hospital discharge is a high-risk phase for patients with advanced cancer, often involving acute-care use that reflects transitional care quality. The impact of inpatient palliative care (PC) consultation on short-term post-discharge outcomes, however, remains uncertain. We assessed whether inpatient PC consultation was associated with differences in 30-day post-discharge outcomes. Using electronic medical records from a tertiary hospital linked with national claims data, we identified patients with lung, stomach, colorectal, liver, or pancreatobiliary cancer who died between 2018 and 2023. Those discharged alive after a hospitalization with inpatient PC consultation were matched 1:1 to patients without PC using propensity scores. Outcomes were 30-day emergency department (ED) visits, hospital readmissions, and intensive care unit (ICU) admissions, 30-day mortality and total direct medical costs. Fine-Gray competing risk and generalized linear models were used for comparisons. Among matched 830 individuals, Thirty-day ED visits (45.8% vs 45.5%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [CI], 0.72 to 1.27) and readmission rates (69.6% vs 72.3%; aOR, 0.86; 95% CI, 0.63 to 1.18) were similar. ICU admission rates were substantially lower among patients receiving PC (1.9% vs 9.2%; aOR, 0.17; 95% CI, 0.07 to 0.37). The total 30-day medical costs were lower in the PC group (cost ratio, 0.65; 95% CI, 0.55 to 0.76). Thirty-day mortality was higher among patients who required PC (37.6% vs 16.1%). Inpatient PC consultation was not associated with 30-day ED visits or hospital readmissions, but was linked to substantially lower ICU admissions and reduced short-term medical costs.

6 Background: Though research shows that patients with terminal illnesses prefer to die at home, over 60% of patients with advanced cancer are hospitalized in the last month of life. Additionally, less than half of these patients receive any form of hospice care at the end of life, despite its demonstrated potential to improve quality of care. Inpatient palliative care (PC) consultations may serve as a bridge from hospitalization to receiving the kind of end-of-life care that patients prefer. Tumors of the gastrointestinal (GI) system include some of the most common and deadliest cancers and these patients can benefit from PC services, especially when the disease has reached an advanced stage. Our objective was to compare the effectiveness of inpatient PC consultations vs. usual care on post-discharge outcomes in patients with advanced GI cancers. Methods: 202 adults with advanced GI cancers admitted to 5 US hospitals were followed prospectively through hospitalization and 6 months post-discharge. 82 patients received a palliative care consult during hospitalization. Propensity scores were used to match treated to control patients, with exposure to a palliative care consult as the intervention. Outcome measures included: referral to hospice, subsequent ER visit, hospital readmission, and place of death. Results: Significantly more patients in the treatment group were referred to hospice upon hospital discharge (38% vs. 8%, p=0.000). 70 patients died in the 6-month follow-up period. Receiving a PC consult increased the odds of dying at home 3-fold (OR=2.9, p=0.046, 95% CI 1.02-8.44) and decreased the odds of dying in a hospital by 85% (OR=0.159, p=0.002, 95% CI 0.05-0.52). At 2 and 6 months post-discharge, significantly more patients in the treatment group were receiving hospice services at death (75% vs. 18%, p=0.001 and 82% vs. 24%, p=0.000 respectively). There were no significant differences between the two groups regarding hospital readmission and ER visits post-discharge. Conclusions: PC consults for patients with advanced GI cancers was associated with increased referral to hospice, decreased likelihood of dying in a hospital and increased likelihood of dying at home.

1432P - The Impact of Palliative Care on the Aggressiveness of End-of-Life Cancer Care in Patients with Advanced Pancreatic Cancer

Outpatient Clinics Are a New Frontier for Palliative Care

Communication: Communication best practices (e.g., teaching goals of care conversations/

Oral Presentation