Palliative care consultation and advance care planning for adults with poor-risk leukemia admitted to an academic medical center.

Abstract

13 Background: Despite high mortality for certain patients with hematologic malignancies, integration of palliative care (PC) and documentation of advance care planning (ACP) is lacking. Our primary objective was to determine the frequency of PC consultation and ACP for inpatients with poor-risk leukemia at our institution. Our secondary objectives were to describe the content of goals of care (GOC) discussions and to characterize PC and end-of-life quality measures. Methods: Chart reviews were conducted for patients with poor risk leukemia (acute leukemia ≥ 65 years or relapsed leukemia > 18 years) admitted to the University of North Carolina from October 1, 2015 to March 31, 2016. The following was abstracted from the chart: demographic data, disease characteristics, presence of a PC consultation, frequency and content of ACP (written advance directive, documented GOC discussion, identified surrogate decision maker), PC quality measures (assessment of pain, dyspnea, nausea, constipation), and end-of-life quality measures (chemotherapy within 14 days of death, ICU stay within 30 days of death, hospice referral less than 3 days prior to death). Results: Thirty-eight subjects were identified. Fifty percent of patients were over age 65 with a new diagnosis of acute leukemia and 50% had relapsed leukemia. The majority of patients (66%) reported pain and 45% reported dyspnea on admission. Sixteen percent of patients died within 30 days of discharge. Eleven percent of patients received PC consultation and 16% had all elements of ACP documented in the chart. GOC discussions without a surrogate decision maker were documented for 37%; content included discussion of values (11%), prognosis (37%), treatment choices (21%), life sustaining preferences (16%), and hospice (21%). Conclusions: In this descriptive study of inpatients with poor-risk leukemia, we found that despite a poor prognosis and high symptom burden, only 11% of patients received PC consultation and 16% had all elements of ACP present in the chart. While our data are limited by documentation, we believe this represents missed opportunities for the delivery of high-quality care.