Aggressive End-of-life Care Research Articles

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 & 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% > 3 Emergency department visits in 1 year 19% 8% Chemotherapy in the last 14 days of life 38% 19% Enrolled in Hospice 14% 54%

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.

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.

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.

Palliative care integration and end-of-life care intensity for patients with NSCLC

BackgroundNon-small cell lung cancer (NSCLC) without oncogenic driver mutations is considered to have a poor prognosis, although recent therapeutic progress. This study aims to assess the real-life integration of palliative care (PC) and the intensity of end-of-life (EOL) care for this population. MethodsThis was an observational cohort study of decedent patients from metastatic NSCLC without oncogenic driver mutations over the period 01/2018 to 12/2022, treated in first line with immunotherapy +/- chemotherapy. We analysed PC integration and aggressiveness criteria of EOL care in the last month before death: systemic anti-cancer treatment administration, emergency room visits, intensive care unit admission, hospitalization, hospitalization duration > 14 days, and hospital death. ResultsAmong 149 patients, 75 (50 %) met the PC team at least once, and the median time from the first encounter to death was 2.3 months. In the last month before death, at least one criterion of aggressive EOL care was present for 97 patients (70 %).For patients with PC use < 30 days and for patients with PC use < 90 days before death, there were significant changes: increase in the frequency of systemic anti-cancer treatment (respectively 51.1 % vs 20 %; p < 0.001 and 58.7 % vs 6.2 %; p < 0.001); decrease in hospitalization lasting > 14 days (respectively 30 % vs 7 %; p = 0.001 and 36 % vs 6.2 %; p = 0.018) and in death hospitalisation (respectively 66 % and 18 %; p < 0.001 and 58.7 % and 10.3 %; p < 0.001).After adjusting for the factors tested, patients with no PC or late PC use in the last month before death or in the last three month before death, the odds ratio (OR) remained significantly greater than 1 (respectively OR = 3.97 [1.70; 9.98]; p = 0.001 and OR = 23.1 [5.21–177.0], p < 0.0001). ConclusionPC is still insufficiently integrated for patients with NSCL cancer. Cancer centres should monitor key indicators such as PC use and aggressiveness criteria of EOL care.

Understanding the Utility of Less Than Six-Month Prognosis Using Administrative Data Among U.S. Nursing Home Residents With Cancer.

There is a dearth of studies evaluating the utility of reporting prognostication among nursing home (NH) residents with cancer. To study factors associated with documented less than six-month prognosis, and its relationship with end-of-life (EOL) care quality measures among residents with cancer. The Surveillance, Epidemiology, and End Results linked with Medicare, and the Minimum Data Set databases was used to identify 20,397 NH residents in the United States with breast, colorectal, lung, pancreatic, or prostate cancer who died between July 2016 and December 2018. Of these, 2205 residents (10.8%) were documented with less than six-month prognosis upon NH admission. Main outcomes were more than one hospitalization, more than one emergency department visit, and any intensive care unit admission within the last 30 days of life as aggressive EOL care markers, as well as admission to hospice, receipt of advance care planning and palliative care, and survival. Specificity and sensitivity of prognosis were assessed using six-month mortality as the outcome. Propensity score matching adjusted for selection biases, and logistic regression examined association. Specificity and sensitivity of documented less than six-month prognosis for mortality were 94.2% and 13.7%, respectively. Residents with documented less than six-month prognosis had greater odds of being admitted to hospice than those without (adjusted odds ratio: 3.27, 95% confidence interval: 2.86-3.62), and lower odds to receive aggressive EOL care. In this cohort study, documented less than six-month prognosis was associated with less aggressive EOL care. Despite its high specificity, however, low sensitivity limits its utility to operationalize care on a larger population of residents with terminal illness.

Sex-Based Analysis of Quality Indicators of End-of-Life Care in Gastrointestinal Malignancies.

Indices of aggressive or supportive end-of-life (EOL) care are used to evaluate health services quality. Disparities according to sex were previously described, with studies showing that male sex is associated with aggressive EOL care. This is a secondary analysis of 69,983 patients who died of a GI malignancy in Ontario between 2006 and 2018. Quality indices from the last 14-30 days of life and aggregate measures for aggressive and supportive EOL care were derived from administrative data. Hospitalizations, emergency department use, intensive care unit admissions, and receipt of chemotherapy were considered indices of aggressive care, while physician house call and palliative home care were considered indices of supportive care. Overall, a smaller proportion of females experienced aggressive care at EOL (14.3% vs. 19.0%, standardized difference = 0.13, where ≥0.1 is a meaningful difference). Over time, rates of aggressive care were stable, while rates of supportive care increased for both sexes. Logistic regression showed that younger females (ages 18-39) had increased odds of experiencing aggressive EOL care (OR 1.71, 95% CI 1.30-2.25), but there was no such association for males. Quality of EOL care varies according to sex, with a smaller proportion of females experiencing aggressive EOL care.

Effects of tertiary palliative care on the pattern of end-of-life care in patients with hematologic malignancies in Korea.

Patients with hematologic malignancies (HMs) often face challenges in accessing palliative care (PC) and receiving quality end-of-life (EOL) care. We examined factors associated with referrals to tertiary PC and the effects of tertiary PC on EOL care in patients with HMs. We included patients with HMs who were admitted to a university-affiliated hospital and died during hospitalization between January 2018 and December 2021. We investigated the receipt of PC consultations, patient characteristics, and EOL care indicators. Overall, 487 patients were included in the analysis, with 156 (32%) undergoing PC consultation. Sex, residence, disease status, and admission purpose were factors associated with the likelihood of PC consultation, and there has been an increasing trend in the frequency of consultations in recent cases. A higher proportion of patients who received PC completed advance statements and life-sustaining treatment documents. Patients who received PC had lower rates of aggressive EOL care, including chemotherapy and intensive care unit admission, than those who did not receive PC. Notably, PC reduced the number of blood transfusions. Tertiary PC aims to reduce aggressive EOL care through patient-centered goal-of-care discussions. Therefore, there is an imperative need for concerted efforts toward seamless integration of PC.

Removing Transfusion Dependence As a Barrier to Hospice Enrollment (BRUOG-407)

Background: Patients with hematologic malignancies (HM) receive more aggressive care at the end of life (EOL) and have suboptimal hospice utilization when compared to patients with solid tumors. One reason for this is a high rate of transfusion dependence (TD). Many hospice agencies decline to provide palliative transfusions because of cost, philosophical objections, and/or logistical barriers, and as a result, many TD patients delay hospice enrollment or never enroll at all. In response to a call from ASH for novel care models to address this issue, we designed a pilot study of an open access transfusion model in hospice care. Our hypothesis was that the provision of transfusions for patients with HM on hospice would be feasible and would result in timely hospice referral and less aggressive EOL care. Methods: We conducted a single-center, prospective pilot study [NCT05063591] enrolling adults with aggressive HM who were TD and hospice-eligible. We concurrently enrolled patients' primary caregivers. Patients were evaluated weekly during a clinic visit or telephone call to assess potential symptoms related to anemia or thrombocytopenia. Relevant symptoms triggered a CBC assessment, and, if appropriate, administration of a transfusion of red blood cells (RBCs) and/or platelets. Caregivers completed the Caregiver Evaluation of Quality of EOL Care survey (CEQUEL, Higgins et al. PLoS One, 2013) ≥1 month after the patient death, to assess perception of the patient's EOL care. The primary outcome was feasibility of the care model, defined as 70% rate of successful enrollment after screening. Secondary outcomes included standard EOL care quality measures: hospice length of stay (LOS), inpatient days and ICU days in the last 30 days of life, inpatient deaths, and the use of chemotherapy in the last 14 days of life. Exploratory outcomes included caregiver's assessment of EOL care quality. Results: Of 22 patients and 9 caregivers screened, 10 patients (45%) and 8 caregivers enrolled. 4 screened patients died before consenting. The median patient age was 80 (range, 69-90). Most patients (90%) had a myeloid malignancy (AML, MDS, or CMML). The mean number of transfusions on study was 2.4 units of RBCs (range, 0-9) and 1.2 units of platelets (range, 0-10) ( Figure). The most common transfusion-triggering symptom was fatigue (N=40 transfusion events), followed by shortness of breath (N=15). The median LOS on hospice was 13 days (range, 4-103; Table). 60% of patients spent &amp;gt;9 days on hospice, and no patient spent ≤ 3 days on hospice. All enrolled patients died outside of the hospital: 60% at home and 40% at inpatient hospice. No patient received chemotherapy within 14 days of death, and 1 (10%) was admitted to the ICU within 30 days of death (prior to trial enrollment). There were no disenrollments due to transfusion reactions. One patient (10%) revoked hospice for hospitalization, but re-enrolled and died in inpatient hospice. When caregivers evaluated their loved one's EOL care, 100% reported that the patient experienced a peaceful death; 100% felt that medical intervention did not result in increased suffering; 86% agreed that EOL was not prolonged by medical intervention longer than they would have wished, and 86% felt that the patient suffered much less than expected. The mean CEQUEL score was 24 (range, 20-26, higher scores indicating a better perception of EOL care). Conclusion: Providing blood transfusions to patients with HM on hospice was feasible in our symptom-driven care model. The enrollment rate was short of the 70% goal, but some screened patients died before enrolling, suggesting that hospice was considered too late in the disease course, and that additional factors beyond TD may contribute to suboptimal hospice utilization among these patients. When compared with our population-based study describing EOL outcomes of patients with HM (Egan et al., Blood Adv. 2020), our current outcomes compare favorably, with longer median time on hospice (13 vs 9 days), fewer hospital deaths (0 vs 27%), and less chemotherapy at the EOL (0 vs 13%). Importantly, caregiver perception of EOL care quality was favorable. Our findings illustrate the potential of palliative blood transfusions to improve the EOL care quality for HM patients on hospice, and highlight the need for earlier hospice referral while pursuing care models that address the specific needs of this unique TD population.

Effect of timing of palliative care consultation on survival and end-of-life care outcomes in mNSCLC.

247 Background: Early 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. However, PC utilization remains low, and treatment paradigms have evolved. We examined how the timing and extent of PC involvement impacted outcomes in patients with mNSCLC in the era of targeted- and immune-therapy. Methods: This 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 and had at least one PC visit. Data were abstracted through November 2022. Patient outcomes data, including the NCCN Distress Thermometer (DT), survival, and EoL care, were analyzed using descriptive statistics. Aggressive EoL care was defined as any cancer-directed therapy, &gt;1 emergency department visit, &gt;1 hospital admission, or &gt;14 days spent in the hospital in the last 30 days of life; or hospice entry within the last 3 days of life or in-hospital death. To examine associations between PC utilization and timing of PC referral with actionable distress we fit generalized estimating equations. Results: The 60 patients were stratified by time to first PC encounter and total number of PC visits. Average age was 63.6 years, 53% were female, and 60% Caucasian. 32% were seen within 2 months of diagnosis (early), 37% between 2-6 months (moderate), and 32% were seen by PC after 6 months (late). 27% of patients saw outpatient PC only once, 43% between 2-4 times, and 30% saw PC 5 or greater times. There was no evidence of an association between PC utilization and actionable distress (NCCN DT score of 4 or greater) nor with timing of PC referral and actionable distress. Median survival was 15.3 months in the early PC group, 6.2 months in the moderate group, and 17.0 months in the late group, with a median survival of 12.5 months. Patients who received early PC spent more time on hospice (45.5 days) compared to those with moderate (29.6 days) and late (22.5 days) PC. Receipt of aggressive EoL care was high overall; 32% of patients with early PC visits received aggressive EoL care compared to 50% in moderate and 63% in late PC groups. Of the 51 decedents, only 30 (59%) enrolled in hospice. 11% of patients in the early PC group died in the hospital, compared to 14% in the moderate and 21% in the late groups. Conclusions: This real-world study reveals that referrals to PC still occur late in the disease course of mNSCLC, despite proven benefits of early integration. Early PC resulted in longer time on hospice, lower frequency of aggressive EoL care, and lower rates of in-hospital death, with no evidence of decreased survival. These findings suggest that early specialist PC improves outcomes in the era of novel mNSCLC therapies, but that PC remains underutilized, and many unmet needs persist in this population.

Non-elective inpatient anti-cancer therapy for solid tumors: To treat or not to treat?

234 Background: Administration of anti-cancer therapy to hospitalized patients is associated with greater treatment-related complications and reduced quality of life. We designed and implemented a standardized process to review all non-elective systemic anti-cancer therapy in solid-tumor patients with the goal of reducing aggressive end of life care and improving quality. Methods: A multidisciplinary group of quality and safety, pharmacy, physician, and nursing leadership designed a workflow to standardize the review of all inpatient anti-cancer treatment requests for non-elective solid-tumor (NEST) patients. Our NEST process begins with a formal pharmacy and nursing review, which can flag a case for further physician review. The pharmacist reviews for adequate hematologic counts, hepatic function, creatinine clearance as well as any active infections requiring IV antibiotics. Then the nursing review assesses treatment plan parameters, patient’s performance status, recent vital signs, and other clinical concerns. If either review flags one or more criteria, the case then goes to physician review. The NEST escalation process includes two levels of physician review – a single reviewer and a committee. If the review determines that there are more potential benefits than risks associated with administering anti-cancer treatment, the treatment can be approved for inpatient administration. However, if the formal review estimates significantly greater risk than potential benefit, the treatment will not be approved for inpatient administration. Results: A total of 58 requests for inpatient anti-cancer therapy occurred between initial implementation (10/31/2022) through 3/31/2023. 82.8% (48/58) were reviewed by both pharmacy and nursing and 45.8% of those were approved without need to escalate. The remaining requests had baseline patient characteristics that triggered physician review - with 13 reviewed by a single physician and 3 requiring committee review. Of the cases requiring further review, 5 did not receive their requested therapy (either denied or the family decided to not pursue treatment). 36.2% (21/58) of NEST patients died within 60 days of process initiation, 22.4% (13/58) died within 30 days, and 13.8% (8/58) died within 10 days. These outcomes were more common in individuals where NEST was denied or inpatient treatment was not pursued (77.8% died within 60 days, 44.4% died within 10 days; note 2 patients discharged to hospice with no death date on record). Conclusions: We designed a formal review process for anti-cancer therapy to be administered in the inpatient setting to solid tumor patients. This multi-disciplinary review led to 15.5% of requests not being administered to patients. Ongoing continuous improvement work focuses on further developing review criteria, exploring options for hard stops prior to treatment administration and increasing earlier goals of care discussions.

Silent Conversations: Goals of Care and End-of-Life Quality in Relapsed High-Risk Leukemia.

Advanced practice providers (APPs) affect high-quality health care through leadership, evidence-based practice implementation, and quality improvement projects. When planning solutions to clinical problems, leadership must solicit APP input to promote success. Hematology patients are more likely to receive poor-quality end-of-life (EOL) care than those with solid tumors. Regardless of disease, aggressive EOL care is increasing despite evidence that it is often inconsistent with patients' goals of care (GOC). Data regarding this phenomenon in hematology specifically is lacking. The distorted association of "end of life" with "goals of care" has "silenced" crucial goals discussions in patients with relapsed or refractory high-risk leukemia, which raises concerns for the provision of care that is inconsistent with patients' values and preferences. Hematologists may possess certain traits and distinct barriers leading to what one might call an aversion to GOC discussions in the inpatient setting. (1) Quantify hematologists' rate of participation in a GOC pathway initiative during two separate months. (2) Explore the hematologists' definition of and barriers to having GOC discussions. This is a mixed-methods, explanatory sequential design (follow-up explanations variant). Quantitative: Hematology inpatient admissions during two nonconsecutive months in 2021. Qualitative: Eighteen leukemia hematologists from one dedicated cancer center. During the 2 months, an average of 36% of admissions met the criteria for GOC pathway initiation, 19% of those had an appropriate initiation order, and < 1% had a properly documented and billed GOC discussion. Nine hematologists responded to a SurveyMonkey poll with two questions. All nine included clinical situation and communication in their definition of GOC discussions. Time limitations and prognostic uncertainty were the two most reported barriers. The findings demonstrate that the apprehension of hematologists to have GOC conversations is similarly seen in the APPs' reluctance to initiate a pathway intended to lead to GOC conversations. The percentage of eligible inpatient admissions meeting the specified criteria was similar between the 2 months; however, the number of appropriate referrals and documented or billed GOC discussions was higher in the earlier month, demonstrating temporal decline. Further research inquiry is needed to explore causation of this phenomenon.

Key components of goals of care conversations on determining end-of-life care for advanced cancer patients.

12130 Background: Early goals of care (GOC) conversations appear to improve end of life (EOL) care in patients with advanced cancer. However, interventions to facilitate GOC conversations may be unsuccessful in changing EOL outcomes due to incomplete understanding of the components of such conversations essential to impacting EOL care. This study seeks to identify the specific components of GOC conversations between patients and oncologists that are associated with less aggressive EOL care. Methods: This was a secondary, sequential mixed-methods analysis of data collected as part of the Values and Options in Cancer Care (VOICE) study, an RCT to improve communication between patients and oncologists. We used qualitative methods to describe and quantify components of GOC conversations occurring in recorded oncology office visits. We then conducted logistic regression analyses to examine the associations between key components identified with less aggressive EOL care. Results: 107 patients who died within 1 year of the recorded visit were included for analysis. Content related to GOC conversations could be found in 80.4% of visits. Most commonly discussed content was related to treatment (72.9%), followed by prognosis (43.9%), EOL care (17.8%), and patient values and preferences (16.8%). In adjusted analyses, discussion of treatment expectation, offer of an alternative to cancer-directed treatment, and mention of hospice were significantly associated with less aggressive EOL care, OR 4.66 (p = 0.047), OR 6.09 (p = 0.008), and OR 7.60 (p = 0.046) respectively. We did not find significant association between discussion of life expectancy and EOL care. Conclusions: GOC conversations may be more effective at impacting EOL care when it includes discussion regarding treatment expectations and offer of an alternative option to cancer-directed therapy, such as hospice.

Quality for all: Clinical trial enrollment and end-of-life care in solid and hematologic malignancies.

12028 Background: All patients with cancer deserve quality end-of-life (EOL) care.Despite established EOL quality metrics, many patients with cancer receive futile, aggressive EOL care with infrequent palliative care involvement and advanced care planning (ACP) documentation. Clinical trials are critical to advancing cancer care; at National Cancer Institute-designated cancer centers, ~20% of patients participate in clinical trials at some point. We aim to identify associations between trial enrollment in the last year of life (YOL) and EOL quality metrics for adults with solid or hematologic malignancies to identify opportunities to advance cancer care near death. Methods: This is a retrospective review of patients with solid or hematologic cancers treated at a single academic institution who died of disease between 2018 – 2022. Patients were identified using institutional registries. Inclusion criteria were ≥18 years of age with active disease at death. Outcomes include: initiation of new anti-cancer therapy, Intensive Care Unit (ICU) admission, hospitalization, or Emergency Department (ED) visit in the last 30 days of life (DOL), referral to hospice, palliative care involvement, and documentation of goals of care (GOC) and ACP paperwork. Results: Among 9,384 patients, 637 (6.8%) enrolled in clinical trials in the last YOL. Most common disease sites were gastrointestinal, thoracic, and genitourinary. Patients enrolled in clinical trials were more likely to initiate new anti-cancer treatments in the last 30 DOL (p=&lt;0.001), less likely to be referred to palliative care (p=0.008) or have GOC documentation (p=&lt;0.001), and less likely to visit the ED (p=0.016) or die in an inpatient setting (p=0.02). No differences were noted in referrals to hospice, ICU or hospital admissions in last 30 DOL, or ACP paperwork. Conclusions: Enrollment in a clinical trial in the last YOL was associated with several measures of aggressive EOL care. Low rates of palliative care and hospice engagement and infrequent documentation of ACP decisions across the study population suggest opportunities for improvement for all patients, regardless of trial enrollment. [Table: see text]

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer. To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts. This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022. Nursing home status. Markers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. The study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]). Despite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

Association between Consultation by a Comprehensive Integrated Palliative Care Program and Quality of End-of-Life Care in Patients with Advanced Cancer in Edmonton, Canada.

Literature assessing the impact of palliative care (PC) consultation on aggressive care at the end of life (EOL) within a comprehensive integrated PC program is limited. We retrospectively reviewed patients with advanced cancer who received oncological care at a Canadian tertiary center, died between April 2013 and March 2014, and had access to PC consultation in all healthcare settings. Administrative databases were linked, and medical records reviewed. Composite score for aggressive EOL care was calculated, assigning a point for each of the following: ≥2 emergency room visits, ≥2 hospitalizations, hospitalization >14 days, ICU admission, and chemotherapy administration in the last 30 days of life, and hospital death. Multivariable logistic regression was adjusted for age, sex, income, cancer type and PC consultation for ≥1 aggressive EOL care indicator. Of 1414 eligible patients, 1111 (78.6%) received PC consultation. In multivariable analysis, PC consultation was independently associated with lower odds of ≥1 aggressive EOL care indicator (OR 0.49, 95% CI 0.38−0.65, p < 0.001). PC consultation >3 versus ≤3 months before death had a greater effect on lower aggressive EOL care (mean composite score 0.59 versus 0.88, p < 0.001). We add evidence that PC consultation is associated with less aggressive care at the EOL for patients with advanced cancer.

End-of-Life Care for Patients With Metastatic Renal Cell Carcinoma in the Era of Oral Anticancer Therapy.

New therapies including oral anticancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC). However, little is known about the quality of end-of-life (EOL) care and systemic therapy use at EOL in patients receiving OAAs or with mRCC. We retrospectively analyzed EOL care for decedents with mRCC in two parallel cohorts: (1) patients (RCC diagnosed 2004-2015) from the University of North Carolina's Cancer Information and Population Health Resource (CIPHR) and (2) patients (diagnosed 2007-2015) from SEER-Medicare. We assessed hospice use in the last 30 days of life and existing measures of poor-quality EOL care: systemic therapy, hospital admission, intensive care unit admission, and > 1 ED visit in the last 30 days of life; hospice initiation in the last 3 days of life; and in-hospital death. Associations between OAA use, patient and provider characteristics, and EOL care were examined using multivariable logistic regression. We identified 410 decedents in the CIPHR cohort (53.4% received OAA) and 1,508 in SEER-Medicare (43.5% received OAA). Prior OAA use was associated with increased systemic therapy in the last 30 days of life in both cohorts (CIPHR: 26.5% v 11.0%; P < .001; SEER-Medicare: 23.4% v 11.7%; P < .001), increased in-hospital death in CIPHR, and increased hospice in the last 30 days in SEER-Medicare. Older patients were less likely to receive systemic therapy or be admitted in the last 30 days or die in hospital. Patients with mRCC who received OAAs and younger patients experienced more aggressive EOL care, suggesting opportunities to optimize high-quality EOL care in these groups.