Aggressive Care Research Articles

Implantable cardioverter defibrillators in people dying with cancer: A SEER-Medicare analysis of ICD prevalence and association with aggressive end-of-life care.

The shared risk profiles for cancer and heart disease suggest many individuals with cancer may have an implantable cardioverter defibrillator (ICD). ICDs can have dramatic cancer end-of-life care implications including painful and distressing shocks. ICD prevalence and association with aggressive end-of-life care among individuals with breast, colorectal, and pancreatic cancer was evaluated using the Surveillance, Epidemiology, and End Results-Medicare dataset. A total of 37,306 Medicare beneficiaries aged ≥66 years with stage 3 or 4 cancer who died between 2005 and 2016 were identified. ICD prevalence, ICD-related care utilization that might present opportunities to discuss end-of-life implications and association with aggressive end-of-life care (>1 emergency department visit, intensive care unit admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive or life-extending procedures) in the last month of life was assessed using multivariable logistic regression. Among cancer decedents, 6% had an ICD. More individuals with an ICD (31%) died in the hospital than individuals without an ICD (25%; p<.001). Half (46%) of individuals with an ICD had device programming or interrogation visits that could be an opportunity for device discussion. In adjusted models, ICD presence was associated with higher odds of every indicator of aggressive end-of-life care other than chemotherapy. Many older cancer decedents in the United States had an ICD, and those with ICDs received more aggressive care at the end of life. Results suggest there are opportunities to discuss ICD and goals of care, raise awareness and encourage shared decision-making for this population to ensure goal-concordant care, and improve end-of-life care quality.

Utilizing metagenomic next-generation sequencing and phylogenetic analysis to identify a rare pediatric case of Naegleria fowleri infection presenting with fulminant myocarditis

BackgroundNaegleria fowleri (N. fowleri), a rare and typically lethal amoeba, most commonly causes primary amoebic meningoencephalitis (PAM). This case report describes an exceptionally rare presentation of fulminant myocarditis as the primary manifestation in a 6-year-old child, diverging from the typical neurological pathogenesis associated with N. fowleri infection. Beyond neurological afflictions, the child developed arrhythmias and cardiac failure, necessitating treatment with extracorporeal membrane oxygenation (ECMO).MethodsDiagnosis was confirmed via metagenomic next-generation sequencing (mNGS) of both blood and cerebrospinal fluid (CSF). This analysis not only substantiated the infection but also revealed a potential new genotype of N. fowleri, designated k39_3, suggesting broader genetic diversity than previously recognized.ResultsImmediate treatment with Amphotericin B (Am B) and rifampin was initiated upon diagnosis. Despite aggressive management and supportive care, the patient failed to maintain hemodynamic stability, continued to show a decrease in cardiac output, and exhibited relentless progression of central nervous system failure, culminating in death within 72 h.ConclusionOur report documents a rare pediatric case of N. fowleri infection presenting with fulminant myocarditis, revealing an unexpected clinical manifestation and broadening the known spectrum of its effects. This emphasizes the need for enhanced surveillance and targeted research to understand the pathogenic mechanisms and improve treatment strategies.

Postoperative rhinosinusitis and microbiological outcomes following endoscopic endonasal approaches: A retrospective analysis of 300 patients.

Endoscopic endonasal approaches (EEAs) are an efficient way to manage skull base lesions; however, studies regarding postoperative rhinosinusitis are limited. This study analyzed the incidence of postoperative rhinosinusitis, the associated risk factors, microbial species, and antibiotic usage in patients who underwent EEA. Patients who underwent EEAs at a tertiary referral hospital between July 2015 and May 2019 were retrospectively evaluated. Postoperative rhinosinusitis was defined as the presence of a purulent nasal discharge on postoperative endoscopic examination. The mucopus was aspirated and subjected to bacterial culture analysis. The culture results of various groups were analyzed. This study included 300 patients, and the incidence of post-EEA rhinosinusitis was 59.7%. History of endonasal surgery was an independent predictive factor for post-EEA rhinosinusitis [OR 2.547 (1.284-5.052), p= 0.007]. Lesions in the anterior skull base were associated with prolonged use of antibiotics for rhinosinusitis during postoperative care [OR 3.914 (1.329-11.524), p=0.013]. Staphylococcus aureus was the most common causative pathogen, followed by methicillin-resistant Staphylococcus aureus (MRSA) (20.7%), Pantoea dispersa (14.4%), and Pseudomonas aeruginosa (11.7%). P. aeruginosa was more significant in the complex reconstruction group than in the control group. While most patients with post-EEA rhinosinusitis experienced a transient clinical course, one female patient underwent ESS for prolonged rhinosinusitis. Rhinosinusitis is common in the postoperative stage of the EEA. As it usually lasts for a short duration and is treatable with proper medication, aggressive nasal care during the postoperative period is required to prevent related nasal morbidities.

Timing of Palliative Care, End-of-Life Quality Indicators, and Health Resource Utilization

Despite research supporting the benefits of early palliative care, timely initiation by gynecologic oncology patients is reportedly low, which may limit the effectiveness of palliative care. To investigate the association of the timing of palliative care initiation with the aggressiveness of end-of-life care using established quality indicators among patients with ovarian cancer. This population-based retrospective cohort study of ovarian cancer decedents used linked administrative health care data to identify palliative care provision across all health care sectors and health care professionals (specialist and nonspecialist) and end-of-life quality indicators in Ontario, Canada, from 2006 to 2018. Data analyses were performed July 12, 2024. The primary outcome was the associations between the timing of palliative care and end-of-life quality indicators, including emergency department use, hospital or intensive care unit admission in the last 30 days of life, chemotherapy in last 14 days of life, death in the hospital, and a composite measure of aggressive care. Late palliative care was defined as 3 months or less prior to death. There were 8297 ovarian cancer decedents. Their mean (SD) age at death was 69.6 (13.1) years, and their mean (SD) oncologic survival was 2.8 (3.9) years. Among 3958 patients with known cancer stage, 3495 (88.3%) presented with stage III or IV disease. One-third of patients (2667 [32.1%]) received late palliative care in the final 3 months of life. Results of multivariable regression analysis indicated that any palliative care initiated earlier than 3 months before death was associated with lower rates of aggressive end-of-life care (odds ratio [OR], 0.47 [95% CI, 0.37-0.60]), death in hospital (OR, 0.54 [95% CI, 0.45-0.65]), and intensive care unit admission (OR, 0.46 [95% CI, 0.27-0.76]). Specialist palliative consultation from 3 months up to 6 monts before death was associated with decreased likelihood of late chemotherapy (OR, 0.46 [95% CI, 0.24-0.88]). Findings from this cohort study suggested that early palliative care may be associated with less-aggressive end-of-life care than late palliative care. Implementation strategies for early palliative care initiation are needed to optimize care quality and health resource utilization at the end of life.

Updates in palliative care of gynecologic oncology patients

Purpose of review This review assesses the impact of early integration of palliative care and the disparities that exist among patients with gynecologic malignancies. It also highlights the recent advances in symptom management, goals of care communication, and end of life care. Recent findings Although palliative care has been utilized earlier, there are still barriers to its integration both nationally and worldwide, manifesting as predominantly late hospice referrals and aggressive care at the end of life. However, there are increasing efforts to promote earlier integration and discussion around goals of care through multidisciplinary approaches. Apart from symptom burdens, patients with gynecologic malignancies experience financial toxicity that impact various aspects of their lives, leading to potentially harmful choices to mitigate costs. A growing area of interest in palliative care is the realm of psychedelic-assisted therapy, which has shown benefits in treating advanced cancer patients with depression. Summary While significant strides have been made in incorporating palliative care earlier, continued research in palliative care is needed to address symptomatic and psychosocial suffering worldwide.

Modulation of Intestinal Flora as an Emerging Therapeutic Approach for the Treatment of Colon Cancer

Abstract: The five-year survival rate for people with colon cancer has increased explosively over the last two decades due to major advances in treatment. Colon cancer survival rates have improved significantly over the past few decades, with some of this success owing to aggressive surgical care and breakthroughs in other complementary treatments. As a new option for Colorectal Cancer (CRC) patients, targeted therapy has been shown to be effective in extending the overall life. A dramatic increase in the number of novel drugs targeting multiple key pathways and immunological checkpoints has been observed after the success of cetuximab (an EGFR inhibitor) and bevacizumab (an anti-angiogenic agent). Neutralizing an already present dysbiosis in the gut microbiome is a novel strategy for combating colorectal cancer and its metastases. Several methods have been employed to date, such as prebiotics, postbiotics, antibiotics, and the transplantation of faecal microbiota. An overview of the epidemiological study and possible mechanisms of colon cancer is presented in this review. We have covered a wide range of targeted treatments for CRC in addition to diagnostic biomarkers as therapeutic targets.

Patients’ understanding of treatment decisions: Impact on major quality metrics and patient informed decision-making at end of life.

170 Background: Blue Ridge Cancer Care (BRCC) is a community oncology practice in rural Virginia and West Virginia. BRCC is an ASCO-certified practice and participates in multiple value-based care programs to ensure a quality improvement and patient-centered approach. BRCC serves regions with low health literacy (LHL) which impacts a patient’s ability to self-manage their disease, make informed health-related decisions, and navigate the health system. The top indicators of LHL are being over 65 years old, having less than any college education, and being insured by Medicare or Medicaid which is 63% of BRCC’s patient population. Methods: BRCC conducted a retrospective analysis of our 2023 end-of-life (EOL) quality measures and 1,682 unique National Comprehensive Cancer Network (NCCN) Distress Tool &amp; Problem List assessments. We then matched the results with each patient’s demographics and disease course. Additional research revealed that LHL levels have the greatest impact on patients engaging in their care and ability to make informed decisions at end of life. Results: 21% of patients reported concerns with understanding treatment decisions (n=353) and they had vastly different outcomes compared to patients that did not have concerns (n=1329). A chi-square test was performed to examine the relation between these events, all outcomes were found to be statistically significant. Detailed outcomes are shown (Table). Conclusions: In our review, patients reporting concerns with or understanding treatment decisions had more aggressive EOL care and used more resources from health care systems. BRCC plans to deepen our understanding of this population by using an evidence-based tool that assess a patient’s understanding of their disease severity, perceived curability, and treatment options to identify gaps in a patient’s prognostic understanding and enhance communication between the care team and better support patients informed decision-making at EOL. Population Reported Concerns with/understanding Treatment Decisions = 21% No Concerns with Treatment Decisions = 79% &gt; 3 Emergency department visits in 1 year 19% 8% Chemotherapy in the last 14 days of life 38% 19% Enrolled in Hospice 14% 54%

LDH and NLR, as inflammatory markers, the independent risk factors for COVID-19 complicated with respiratory failure in elderly patients.

Lactate dehydrogenase (LDH) is an enzyme that is responsible for the production of lactic acid, which is a necessary byproduct when the body does not have enough oxygen. LDH levels in the blood can be used as a marker to predict mortality in patients with ARDS, severe COVID-19, and cancer. To analyze the clinical characteristics of COVID-19 in the elderly and the correlation between LDH and respiratory failure in COVID-19 patients, to improve the identification and management of this type of pneumonia by clinicians. This was a single-center retrospective study. We performed routine laboratory tests in 105 COVID-19 patients admitted to the affiliated hospital of Qingdao University (Qingdao, China) from October 1, 2022 to February 1, 2023. The diagnosis of respiratory failure was established based on the results of blood gas analysis upon admission. The median age was 79 years. Among all univariable parameters, LDH, neutrophil to lymphocyte ratio (NLR) and Prothrombin Time (PT) were significantly independent risk factors of RF in elderly COVID-19 patients. LDH (AUC=0.829) also had a maximum specificity (96.5%), with the cutoff value of 280.5. The levels of LDH, NLR, and PT may serve as potential indicators for elderly COVID-19 patients combined with respiratory failure. LDH, NLR and PT assays can be beneficial for patients who need closer respiratory monitoring and more aggressive supportive care to prevent a negative prognosis.

Racial disparities in end-of-life care among patients with neuroendocrine tumors.

60 Background: Due to the rising incidence of neuroendocrine tumors (NETs), the prevalence of NETs now surpasses many other malignancies. Due to a slower course of disease and lack of awareness among care teams, end-of-life (EOL) care is typically underutilized in patients with NETs. Owing to a heavy symptom burden (related to disease burden and/or functionality), patients with NETs often struggle due to lack of palliative care and eventually EOL care support. Prior studies have revealed that Black patients with advanced cancer are more likely to receive aggressive care and suffer a significant decline in quality of life at EOL. However, similar data investigating racial differences in EOL among patients with NETs are lacking. Methods: The National Inpatient Sample (NIS) was queried between years 2016-2020 to identify all hospitalizations (regardless of site of origin) with NETs utilizing the appropriate ICD-10 codes (neuroendocrine carcinomas were excluded). Hospitalizations of White and Black patients with documented inpatient mortality events were then extracted. Demographic and clinical data were analyzed using independent sample t-test, Chi-square test, and binary logistic regression (adjusted for age, gender, and Charlson comorbidity index or CCI). NIS discharge weights were applied to calculate national estimates. Statistical analyses were performed with SPSS 28.0. A p-value of &lt;0.05 was considered statistically significant. Results: A total of 6,265 hospitalizations with NETs were included, of which 5,125 (81.8%) and 1,140 (18.2%) had White and Black patients respectively. Black patients were younger, more likely to be females, and less likely to have a do not resuscitate (DNR) code status. There was no significant difference in CCI between the groups. Palliative care consultation was less likely to be performed among Black patients (adjusted OR=0.70, p&lt;.001). Black patients also had longer mean length of stay in the hospital (10.25 vs 8.42 days, p&lt;.001). Black patients were also more likely to receive aggressive care in the form of mechanical ventilation at EOL (Table). Conclusions: This is the largest analysis demonstrating significant racial disparities in EOL care among patients with NETs. Black patients had longer inpatient stay, were less likely to receive inpatient palliative care consultation, have a DNR order and more likely to receive aggressive care at EOL. These findings may have implications for informing healthcare decision making for EOL care among Black patients with NETs. WhiteN=5125 BlackN=1140 aOR (95% CI) p-value Age (years) 67.67 ± 11.89 65.14 ± 11.29 - &lt;.001 Females 46.1% 50.9% - .004 CCI 11.0 ± 3.22 10.9 ± 3.42 - .538 Mean length of stay 8.42 ± 10.03 10.25 ± 15.75 - &lt;.001 Palliative 62.6% 54.5% 0.70 (.61-.80) &lt;.001 DNR 64.9% 60.1% 0.80 (.70-.92) .002 Blood transfusion 13.2% 15.4% 1.18 (.98-1.41) .052 Mechanical ventilation 28.8% 38.6% 1.55 (1.35-1.77) &lt;.001 Vasopressor 9% 9.6% 1.07 (.86-1.33) .47

Comparison of the Effectiveness of Risk Models Used in Acute Promyelocytic Leukemia

Newly diagnosed acute promyelocytic leukemia (APL) patients were evaluated, and the effectiveness of the Sanz risk model was compared with other risk models developed for early mortality. To determine a simple, reliable, and highly effective risk model used in clinical practice for earlier recognition of high-risk patients at high risk of mortality. This is a retrospective analysis of 57 patients diagnosed with APL in our clinic between January 2002 and June 2019. Patients were grouped under the risk models of Sanz score, modified Sanz risk score, the International Society on Thrombosis and Haemostasis (ISTH), and other scores by Österroos et al. and Cai et al. We found higher white blood count (WBC) is independently associated with 30-day mortality [Odds ratio (OR): 1.030, 95% confidence interval (CI): 1.005 - 1.055, p= 0.017]. Albumin, another variable included in the multivariable model, was found non-significant (p= 0.055). The modified Sanz risk score had a sensitivity of 77.78% and specificity of 66.67% to predict 30-day mortality for high and ultra-high-risk patients [Area under the curve (AUC): 0.727, 95% CI: 0.514 - 0.939, p= 0.032]. Additionally, the AUC of the modified Sanz risk score was significantly higher than the Sanz risk score (p= 0.028). We found no significant difference between the AUC of the Sanz risk score and Österroos et al.’s, Cai et al.’s, and ISTH risk scores. Timely recognition of high-risk patients, taking appropriate protective measures, and administering more aggressive supportive care can help reduce the early mortality of APL patients. Sanz risk score and other scoring systems have been guiding the identification of high-risk APL patients. However, the most effective scoring system could not be determined at the end of the study. There is still a need for standardized scoring systems to identify high-risk patients more effectively, including comorbidities. Keywords: Acute promyelocytic leukemia, Early mortality, Modified Sanz risk score, Risk scores

Associations between perceived interpersonal support and aggressiveness of care in the last month of life among patients with advanced cancer.

To determine quality of life (QoL) domains in the months leading up to death associated with the receipt of aggressive care in the last month of life among patients with advanced cancer. A multisite, prospective cohort study conducted from January 2010 to May 2015 of 59 patients with advanced cancer (distant metastases and/or progression of disease following at least first-line chemotherapy) and poor prognosis (≤ 6months) followed through death. At baseline, a median of 4months from death, the McGill Quality of Life Questionnaire measured overall QoL and four QoL domains (i.e., interpersonal support, physical well-being, psychological, and existential). Postmortem data were collected via medical chart review and nurse/caregiver report and combined to capture the aggressiveness of end-of-life (EoL) care in patients' last month of life. Aggressive EoL care was defined as any receipt of care in an intensive care unit, being on a ventilator, or chemotherapy in the last month of life. Patients with higher interpersonal support domain scores (i.e., rating the world as more "caring and responsive" to their needs and their felt support as more complete) received significantly less aggressive care in their last month of life (odds ratio = 0.39, 95% confidence interval 0.20 to 0.75, p = 0.004). Perceived interpersonal support is the only QoL domain assessed that was associated with aggressiveness of care in the last month of life for patients with advanced cancer. Prioritizing caring and responsive relationships for patients may decrease receipt of aggressive EoL care.

Aggressive Hyperkalemia Treatment in the Prehospital Setting

This is a case of profound unstable hyperkalemia encountered in the American pre-hospital 911 setting, with subsequent aggressive treatment and stabilization. Although hyperkalemia may be present in the prehospital setting, it is difficult to diagnose without laboratory testing or a reliable history of illness. It is frequently encountered in the pre-hospital setting, especially in communities with high levels of comorbidities and multiple dialysis centers. However, in the spectrum of hyperkalemia presentations, many of these patients are either early in their disease presentation or found when already in cardiac arrest. Early identification and rapid, aggressive treatment are paramount to decreasing morbidity and mortality in these patient populations. This case shows how aggressive prehospital critical care can have a significant impact on patient outcomes.

Paying for advance care planning in medicare: Impacts on care and spending near end of life

Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP)—the process of discussing and recording patient preferences for goals of care—on care utilization, spending, and mortality outcomes for critically ill Medicare patients. We find that billed ACP services substantially increase hospice use and hospice spending within a year, accompanied by corresponding increase in one-year mortality. The impacts of ACP services on hospice use and spending are especially prominent among patients with dementia and those of lower socioeconomic status. Among decedents, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. Our findings suggest that paying for ACP services can be effective in improving hospice use for critically ill Medicare patients, with the (possibly intended) consequence of increased one-year mortality.

End of life care for people with dementia and comorbid cancer: recent studies and research gaps.

This narrative review examines recent research on end of life (EOL) care for people with dementia and comorbid cancer, highlighting the complexity and challenge of providing effective EOL care for this group and areas of interest for future research. People with cancer and dementia and their family/supporters have more complex care and support needs at EOL that are less well met than those of older adults with cancer alone, including questionable use of aggressive EOL care interventions, poorer access to specialist palliative care teams and poor pain management. Those diagnosed with dementia at the same time as, or after their cancer diagnosis, are at greater risk of aggressive EOL care and EOL cancer treatment and care plans that are not able to meet their care needs as dementia progresses. There is a lack of research on EOL care for people with cancer and dementia. There is little understanding of what good care for this population looks like and if and how EOL care can best meet the needs of people with cancer and dementia or their carers/supporters. More research is needed to inform improved care for this population.

Timing of Palliative Care Consultation Impacts End of Life Care Outcomes in Metastatic Non-Small Cell Lung Cancer

ContextEarly specialist palliative care (PC) involvement in metastatic non-small cell lung cancer (mNSCLC) is associated with improved quality of life, less aggressive end of life (EoL) care, and longer survival. As treatment paradigms for NSCLC have evolved, PC utilization remains low. ObjectivesThis work examines how the timing and extent of PC involvement impacts outcomes and the patient experience in mNSCLC in the era of immunotherapy. MethodsThis retrospective review analyzed patients with mNSCLC who initiated first-line treatment with chemotherapy, immunotherapy, or combined chemoimmunotherapy at Duke University between March 2015 and July 2019. PC consultation and outcomes data were abstracted through November 2022. EoL care variables were analyzed using descriptive statistics. Results152 patients were stratified based on whether PC was consulted during their disease course. 80 patients (53%) never saw PC, while the 72 patients (47%) who saw PC were further stratified by time to first PC encounter and total number of PC visits. 31% were seen within two months of diagnosis (early), 33% between two and six months (intermediate), and 36% after 6 months (late). Patients who received early PC had longer median time on hospice (35 days), had lower rates of aggressive EoL care (43%), and experienced less frequent in-hospital death (14%) compared to other groups. ConclusionThis real-world study reveals that referrals to PC still occur late or not at all in mNSCLC despite demonstrated benefits of early PC integration. Early outpatient PC referrals resulted in longer time on hospice, lower frequency of aggressive EoL care, and lower rates of in-hospital death.

Current status of advance care planning, palliative care consultation, and end-of-life care in patients with glioblastoma in South Korea.

Given the typical trajectory of glioblastoma, many patients lose decision-making capacity over time, which can lead to inadequate advance care planning (ACP) and end-of-life (EOL) care. We aimed to evaluate patients' current ACP and EOL care status. We conducted a cohort study on 205 patients referred to oncologists at a Korean tertiary hospital between 2017 and 2022. We collected information on sociodemographic factors, cancer treatment, palliative care consultation, ACP, legal documents on life-sustaining treatment (LST) decisions, and aggressiveness of EOL care. With a median follow-up time of 18.3 months: 159 patients died; median overall survival: 20.3 months. Of the 159 patients, 11 (6.9%) and 63 (39.6%) had advance directive (AD) and LST plans, respectively, whereas 85 (53.5%) had neither. Among the 63 with LST plans, 10 (15.9%) and 53 (84.1%) completed their forms through self-determination and family determination, respectively. Of the 159 patients who died, 102 (64.2%) received palliative care consultation (median time: 44 days from the first consultation to death) and 78 (49.1%) received aggressive EOL care. Those receiving palliative care consultations were less likely to receive aggressive EOL care (83.3% vs 32.4%, P < .001), and more likely to use more than 3 days of hospice care at EOL (19.6% vs 68.0%, P < .001). The right to self-determination remains poorly protected among patients with glioblastoma, with nearly 90% not self-completing AD or LST plan. As palliative care consultation is associated with less aggressive EOL care and longer use of hospice care, physicians should promptly introduce patients to ACP conversations and palliative care consultations.

Management of serotonin syndrome (toxicity)

Serotonin syndrome (toxicity), resulting from an excessive accumulation of serotonin in the central nervous system, it can occur due to various factors such as the initiation of medication, overdose or drug interactions. Diagnosing serotonin toxicity presents challenges as there are no definitive criteria. This review delves into the pathophysiology, incidence, clinical assessment and management of serotonin toxicity, stressing the significance of promptly recognizing and managing severe cases. Diagnosis relies primarily relies on clinical assessment due to the absence of specific laboratory tests. The Hunter Serotonin Toxicity criteria are commonly utilized but have only been validated in the overdose setting. Assessing the severity of toxicity is crucial for guiding management decisions. Supportive care, discontinuation of causative agents and symptomatic treatment are prioritized in management. Mild toxicity often requires withdrawal or reduction of the serotonergic agent, while more severe toxicity requires more aggressive resuscitative and supportive care. Severe serotonin toxicity characterized by hyperthermia and rigidity requires aggressive supportive measures, including benzodiazepines, intubation, paralysis and active cooling. Animal studies suggest potential benefits of 5-HT2A receptor antagonists in preventing hyperthermia and fatalities, but only at high doses. Their clinical effectiveness remains uncertain, and evidence is predominately from case series and case reports. Although commonly used, serotonin antagonists like cyproheptadine lack conclusive evidence of efficacy. Other serotonin antagonists such as chlorpromazine and olanzapine have been explored but evidence is limited to case reports. Hence, the cornerstone of treating severe cases does not lie in 'antidote' administration or even diagnosis but in effective early resuscitative and supportive care.

Decreased aggressive care at the end of life among advanced cancer patients in the Republic of Korea: a nationwide study from 2012 to 2018

BackgroundThis study aimed to investigate the trends of aggressive care at the end-of-life (EoL) for patients with advanced cancer in Korea and to identify factors affecting such care analyzing nationwide data between 2012 to 2018.MethodsThis was a population-based, retrospective nationwide study. We used administrative data from the National Health Insurance Service and the Korea Central Cancer Registry to analyze 125,350 patients aged 20 years and above who died within one year of a stage IV cancer diagnosis between 2012 and 2018.ResultsThe overall aggressiveness of EoL care decreased between 2012 and 2018. In patients’ last month of life, chemotherapy use (37.1% to 32.3%; p < 0.05), cardiopulmonary resuscitation (13.2% to 10.4%; p < 0.05), and intensive care unit admission (15.2% to 11.1%; p < 0.05) decreased during the study period, although no significant trend was noted in the number of emergency room visits. A steep increase was seen in inpatient hospice use in the last month of life (8.6% to 26.6%; p < 0.05), while downward trends were observed for hospice admission within three days prior to death (13.9% to 11%; p < 0.05). Patients were more likely to receive aggressive EoL care if they were younger, women, had treatment in tertiary hospitals, or had hematologic malignancies. In the subgroup analysis, the overall trend of aggressive EoL care decreased for all five major cancer types.ConclusionThe aggressiveness of EoL care in stage IV cancer patients showed an overall decrease during 2012–2018 in Korea.

Association of socioeconomic status with aggressive end-of-life care in patients with cancer before and during the COVID-19 pandemic.

1612 Background: Aggressive care near the end-of-life (EOL) reflects poor quality of cancer care.We examined the association between trends in aggressive EOL cancer care and socioeconomic status (SES) before and during the COVID-19 pandemic. Methods: We conducted a population-based cohort study of adults diagnosed with cancer who died from 03/16/2015 to 03/15/2020 (pre-COVID-19 period) and from 03/16/2020 to 03/15/2021 (COVID-19 period). Aggressive EOL care was defined as a composite outcome of percentage (%) of patients with systemic anticancer therapy (SACT) use, &gt;1 ED visit, &gt;1 hospitalization, or ≥1 ICU admission in the last 30 days of life. We conducted an interrupted time series analysis using segmented linear regression, estimating monthly trends before, at the start of, and during the first year of the pandemic. Analyses were stratified by SES, based on area-level material deprivation quintiles (Q1, least; Q3, intermediate; Q5, most deprived). Results: Of 173,915 decedents with cancer (mean [SD] age 72.1 [12.5] years; females 45.9%), 59,613 (34.3% [95% CI, 34.1-34.5]) had aggressive EOL care; 10.3% (10.2-10.5) received SACT, 14.0% (13.8-14.2) had &gt;1 ED visit, 10.3% (10.2-10.5) &gt;1 hospitalization, and 13.4% (13.2-13.5) ≥1 ICU admission within 30 days of death. During the course of the pre-COVID-19 period, patients in Q1 (33.5% [33.0-34.1]) were less likely to receive aggressive care at the EOL than those in Q3 (34.1% [33.5-34.6]) or Q5 (34.8%, 95% CI, 34.3-35.3). Specifically, patients in Q1 were less likely to have ED visits (Q1, 12.9% vs Q3, 14.2% vs Q5, 14.9%), and hospitalizations (9.7% vs 10.3% vs 10.6%) than Q3 and Q5, and less likely to have ICU admissions than Q5 (13.1 vs 13.0% vs 14.4%); however, they were more likely to receive SACT at EOL (11.1% vs 9.9% vs 9.1%). During the pre-COVID-19 period, aggressive care increased by 0.032% (95% CI, 0.026-0.038, P &lt; 0.0001) monthly; this increase was significant in Q1 (P = 0.002)but not in Q3 (P = 0.31) or Q5 (P = 0.21). Within Q1, there was a pre-COVID-19 increase in EOL SACT use (P &lt; 0.0001)and ED visits (P = 0.04) but not inhospitalizations and ICU admissions. In March 2020, aggressiveness of care decreased by 2.37% (95% CI, -2.98 to -1.76, P = 0.0002), which was significant in Q5 (P = 0.04), but not Q1 (P = 0.07)or Q3 (P = 0.81). Within Q5, there was a decrease in EOL ED visits (P = 0.0008) but not in SACT use, hospitalizations, or ICU admissions. Conclusions: More than one third of adults with advanced cancer received aggressive EOL care, which increased in the 5 years prior to COVID-19 pandemic and was attenuated at its onset. Indicators of aggressive care differed by SES, with greatest SACT use in those with highest SES and greatest hospital services use in those with lowest SES. Measures to reduce aggressiveness of care should take into account disparities related to SES.

Using machine learning for targeted advance care planning (ACP) conversations in patients with cancer: A quality improvement initiative.

1552 Background: Despite improvements, patients with advanced cancer often do not receive goal-concordant care at the end of life (EOL). Challenges with prognostication contribute to delays ACP conversations and result in more aggressive care, gaps in symptom management, and hospice underuse. Early identification of patients at high risk for mortality provides an avenue to implement targeted ACP conversations. Methods: We used a validated machine learning model that integrates demographics, lab values, vital signs, and medications to predict in-hospital, 30-day, and 6-month mortality risk for patients with a solid malignancy admitted from the emergency department (ED) to a dedicated solid malignancy oncology unit at Duke University Hospital. This unit includes one oncology and one palliative care attending physician, advance practice providers, and nurse coordinators. Providers received an email when a patient was identified as high risk for mortality. A pre-post study design compared ACP documentation and other EOL healthcare utilization before and after the notification intervention. The pre-intervention cohort included patients hospitalized from 1/7/2019 to 10/25/2019 and the post-intervention cohort from 9/19/2020 to 8/31/2021. We excluded patients admitted to the intensive care unit in the first 24 hours. We used chi-square or Fisher’s exact tests for categorical variables and Kruskal-Wallis tests for continuous variables; we stratified comparisons of categorical variables by physician division using Cochran-Mantel-Haenszel tests. Results: The pre-intervention cohort comprised 105 hospitalizations and 88 unique patients. Mean (SD) age was 64.9 (11.4); 60.0% (n=63) were White, 3.8% (4) Hispanic/Latino, and 65.7% (69) married. The post-intervention cohort comprised 84 hospitalizations and 77 patients. Mean (SD) age was 66.0 (12.2); 52.4% (44) were White, 2.4% (2) Hispanic/Latino, and 60.7% (51) married. Considering index hospitalizations, an ACP note was written for 2.3% (2) of hospitalizations pre-intervention vs. 80.5% (62) post-intervention (p &lt;0.0001). This relationship held even if the physician was in palliative care (4.1% [2] vs. 84.6% [33]) or oncology (0% [0] vs. 76.3% [29]) (p &lt;0.0001). Inpatient length of stay (LOS), hospice referral, code status change, ICU admission rate or LOS, 30-day readmissions, 30-day ED visits, and inpatient and 30-day deaths did not differ significantly between groups. Conclusions: Identification of hospitalized cancer patients with high mortality risk via machine learning led to a substantial increase in documented ACP conversations but did not impact EOL healthcare utilization. Further integration of the model in clinical practice is ongoing. Our intervention showed promise in changing clinician behavior, and additional work is needed to evaluate downstream impacts.