Benefits Of Early Palliative Care Research Articles

US Medicare Hospice and Palliative Medicine Physician Workforce and Service Delivery in 2008-2020

ContextDespite clinical benefits of early palliative care, little is known about Medicare physician workforce specialized in Hospice and Palliative Medicine (HPM) and their service delivery settings. ObjectivesTo examine changes in Medicare HPM physician workforce and their service delivery settings in 2008–2020. MethodsUsing the Medicare Data on Provider Practice and Specialty from 2008 to 2020, we identified 2375 unique Medicare Fee-For-Service (FFS) physicians (15,565 physician-year observations) with self-reported specialty in “Palliative Care and Hospice”. We examined changes in the annual number of HPM physicians, average number of Medicare services overall and by care setting, total number of Medicare FFS beneficiaries, and total Medicare allowed charges billed by the physician. ResultsThe number of Medicare HPM physicians increased 2.32 times from 771 in 2008 to 1790 in 2020. The percent of HPM physicians practicing in metropolitan areas increased from 90% to 96% in 2008–2020. Faster growth was also observed in female physicians (52.4% to 60.1%). Between 2008 and 2020, we observed decreased average annual Medicare FFS beneficiaries (170 to 123), number of FFS services (467 to 335), and Medicare allowed charges billed by the physician ($47,230 to $37,323). The share of palliative care delivered in inpatient settings increased from 47% to 68% in 2008–2020; whereas the share of services delivered in outpatient settings decreased from 37% to 19%. ConclusionDespite growth in Medicare HPM physician workforce, access is disproportionately concentrated in metropolitan and inpatient settings. This may limit receipt of early outpatient specialized palliative care, especially in nonmetropolitan areas.

Impact of early palliative care on healthcare utilization in patients with advanced lung cancer in the final year of life.

239 Background: The benefits of early palliative care (PC) in advanced lung cancer are well established, including both increased quality of life and decreased hospital costs at end-of-life. We performed a quantitative and preliminary qualitative analysis on end-of-life healthcare utilization of patients with advanced lung cancer in their final year of life to explore the impact of early vs. late PC. Methods: We retrospectively reviewed claims and clinical data of 54 patients with advanced lung cancer who died between 2021 and 2022 under Northwestern Medicine’s Accountable Care Organization. We classified patients as having received PC if a diagnosis code (Z51.5) appeared in claims data or if the patient’s treatment team included a PC specialist. We identified patients as having received “early” PC if their first PC visit was 90 or more days before death. Statistical analysis was performed with Fisher exact tests. Results: Forty-three (80%) patients had a PC code on claims data, while 38 (70%) had a PC team member identified within the electronic medical record. Patients receiving PC were less likely to visit the emergency department in their last 6 months of life (71% vs. 94%, p = 0.03) and more likely to utilize hospice (53% vs. 44%, p = 0.27) compared to patients without PC. Patients receiving early vs. late PC were more likely to have initiated PC as an outpatient (67% vs. 31%, p = 0.02), more likely to utilize hospice (57% vs. 44%, p = 0.21), more likely to have shorter intensive care unit stays in their last month of life (average of 10 vs. 25 days), and significantly less likely to undergo systemic treatment in their last 30 days of life (24% vs. 56%, p = 0.02) or die in the hospital (29% vs. 56%, p = 0.04). From a preliminary qualitative review, patients receiving early PC may have engaged in increased communication about clinical prognosis and goals of care, while their PC teams provided more detailed documentation of conversations about end-of-life wishes and advanced directives. Conclusions: Our data demonstrate a difference in end-of-life healthcare utilization between patients who received early vs. late PC. Limitations of this study include its small sample size and the nature of retrospective cohort studies. Qualitative evaluation is ongoing to investigate the impact of early oncologist-driven goals of care discussions on end-of-life healthcare utilization as well as moderators of early palliative care’s positive impact.

Personalized Palliative and Survivorship Care for Patients With Metastatic Cancer Treated With Radiation Therapy.

While the benefits of early palliative care for patients with metastatic cancer are well established, cancer survivorship remains inadequately integrated into the care of patients with distant metastases. Moreover, the optimal model of care delivery is poorly defined. A prognostic model previously developed and validated at Good Samaritan University Hospital identified four groups of patients with metastatic solid tumor malignancy having very favorable, favorable, standard or unfavorable prognoses with median survival of 31, 14, 4 and 1 month, respectively. This framework holds promise for the personalized delivery of supportive, palliative and survivorship care services in the context of radiation therapy. We review the published literature providing the rationale for a novel multidisciplinary care model where the radiation oncology Clinical Nurse Specialist identifies and coordinates interventions to address unmet physical and emotional issues faced by survivors with metastatic cancer with the goal of improving quality of life and overall survival.

Integrating Palliative Care into Oncology Care Worldwide: The Right Care in the Right Place at the Right Time.

While the benefits of early palliative care are indisputable, most of the current evidence has emerged from resource-rich settings in urban areas of high-income countries, with an emphasis on solid tumors in outpatient settings; this model of palliative care integration is not currently scalable internationally. A shortage of specialist palliative care clinicians means that in order to meet the needs of all patients who require support at any point along their advanced cancer trajectory, palliative care must also be provided by family physicians and oncology clinicians who require training and mentorship. Models of care that facilitate the timely provision of seamless palliative care across all settings (inpatient, outpatient, and home-based care), with clear communication between clinicians, are crucial to the provision of patient-centred palliative care. The unique needs of patients with hematological malignancies must be further explored and existing models of palliative care provision modified to meet these needs. Finally, care must be provided in an equitable and culturally sensitive manner, recognizing the challenges associated with the delivery of high-quality palliative care to both patients in high-income countries who live in rural areas, as well as to those in low- and middle-income countries. A one-size-fits-all model will not suffice, and there is an urgent need to develop innovative context-specific models of palliative care integration worldwide, in order to provide the right care, in the right place, and at the right time.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team.

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care. This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task. An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care. This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

The feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial.

BackgroundWhile multiple clinical trials have demonstrated benefits of early palliative care for people with cancer, access to these services is frequently very late if at all. Establishing evidence-based, disease-specific ‘triggers’ or times for the routine integration of early palliative care may address this evidence-practice gap.AimTo test the feasibility of using defined triggers for the integration of standardised, early palliative (STEP) care across three advanced cancers.MethodPhase II, multi-site, open-label, parallel-arm, randomised trial of usual best practice cancer care +/- STEP Care conducted in four metropolitan tertiary cancer services in Melbourne, Australia in patients with advanced breast, prostate and brain cancer. The primary outcome was the feasibility of using triggers for times of integration of STEP Care, defined as enrolment of at least 30 patients per cancer in 24 months. Triggers were based on hospital admission with metastatic disease (for breast and prostate cancer), or development of disease recurrence (for brain tumour cohort). A mixed method study design was employed to understand issues of feasibility and acceptability underpinning trigger points.ResultsThe triggers underpinning times for the integration of STEP care were shown to be feasible for brain but not breast or prostate cancers, with enrolment of 49, 6 and 10 patients across the three disease groups respectively. The varied feasibility across these cancer groups suggested some important characteristics of triggers which may aid their utility in future work.ConclusionsAchieving the implementation of early palliative care as a standardized component of quality care for all oncology patients will require further attention to defining triggers. Triggers which are 1) linked to objective points within the illness course (not dependent on recognition by individual clinicians), 2) Identifiable and visible (heralded through established service-level activities) and 3) Not reliant upon additional screening measures may enhance their feasibility.

Is the use of palliative care services increasing? A comparison of current versus historical palliative care access using health service datasets for patients with cancer

Background: Mature evidence exists supporting the integration of palliative care in cancer care, but translation of evidence into practice is less well understood. Aim: We sought to understand current access to palliative care and its timing for people with cancer and to compare practices over time. Design: We conducted a retrospective population cohort study using routinely collected administrative health data sets in Victoria, Australia. Setting/Participants: All adult cancer decedents in 2018 were identified and clinical, demographic, palliative care access and quality of end of life care indices collected. Comparisons between a historic cohort of lung, breast and prostate cancer patients who died between the years 2005 and 2009 and those with these diagnoses in the current cohort. Results: In 2018 there were 10,245 Victorian decedents with a cancer-coded cause of death, of these 3689 had lung, prostate or breast cancer. In 2018, access to palliative care increased (66% vs 54%) and greater numbers accessed palliative care more than 3 months before death (18% vs 10%) than in 2005–2009. Indices of end of life quality improved across most domains. However the median time between first palliative care and death was shorter in 2018 (22 vs 25 days) and more people first accessed palliative care in the hospitalisation during which they died (43% vs 33%). Conclusion: Despite established benefits of early palliative care, the important task of translation of this evidence into practice remains.

Changes in Cancer Patients' and Caregivers' Disease Perceptions While Receiving Early Palliative Care: A Qualitative and Quantitative Analysis.

BackgroundLittle is known about the underlying mechanisms through which early palliative care (EPC) improves multiple outcomes in patients with cancer and their caregivers. The aim of this study was to qualitatively and quantitatively analyze patients’ and caregivers’ thoughts and emotional and cognitive perceptions about the disease prior to and during the EPC intervention, and in the end of life, following the exposure to EPC.Materials and MethodsSeventy‐seven patients with advanced cancer and 48 caregivers from two cancer centers participated in semistructured interviews. Their reports were qualitatively and quantitatively analyzed by the means of the grounded theory and a text‐analysis program.ResultsParticipants reported their past as overwhelmed by unmanaged symptoms, with detrimental physical and psychosocial consequences. The EPC intervention allowed a prompt resolution of symptoms and of their consequences and empowerment, an appreciation of its multidimensional approach, its focus on the person and its environment, and the need for EPC for oncologic populations. Patients reported that conversations with the EPC team increased their acceptance of end of life and their expectation of a painless future. Quantitative analysis revealed higher use of Negative Affects (p < .001) and Biological Processes words (p < .001) when discussing the past; Agency words when discussing the present (p < .001); Positive Affects (p < .001), Optimism (p = .002), and Insight Thinking words (p < .001) when discussing the present and the future; and Anxiety (p = .002) and Sadness words (p = .003) when discussing the future.ConclusionOverall, participants perceived EPC to be beneficial. Our findings suggest that emotional and cognitive processes centered on communication underlie the benefits experienced by participants on EPC.Implications for PracticeBy qualitative and quantitative analyses of the emotional and cognitive perceptions of cancer patients and their caregivers about their experiences before and during EPC interventions, this study may help physicians/nurses to focus on the disease perception by patients/caregivers and the benefits of EPC, as a standard practice. The analysis of words used by patients/caregivers provides a proxy for their psychological condition and support in tailoring an EPC intervention, based on individual needs. This study highlights that the relationship of the triad EPC team/patients/caregivers may rise as a therapeutic tool, allowing increasing awareness and progressive acceptance of the idea of death.

AML-084: Feasibility Study Integrating Electronic Patient-Reported Outcomes (PROs) and Palliative Care for High-Risk Acute Myeloid Leukemia (AML) Patients

Context: Despite recent lower-intensity therapies that have improved outcomes for older AML patients, AML remains associated with poor prognosis as well as high symptom burden. While the benefits of early palliative care and electronic PROs have been well-described in oncology patients, neither have been well-studied in AML, and they have never been studied in combination. Objective: To evaluate the feasibility of a virtually mediated supportive care model utilizing both electronic PROs and palliative care for patients with AML being treated with lower-intensity therapy (NCT04885127). Design: This will be a prospective, single-arm, non-blinded trial with a year of enrollment and six months of follow-up. Setting: All patients will be enrolled at Stanford Comprehensive Cancer Center. Patients or Other Participants: We plan on enrolling 40 patients who are on first-line lower-intensity therapy for AML, defined as therapy that allows patients to receive care exclusively in the outpatient setting. Interventions: Patients who are enrolled will be referred to the subspecialty palliative care clinic for virtual consultation and monthly follow-up visits for 6 months. Patients will also be instructed on the use of Noona, a digital application that allows real-time, remote monitoring of PROs. Patients will be requested to fill out a Noona symptom questionnaire prior to each palliative care visit and will be prompted to maintain a weekly symptom diary, which will be available to both their primary leukemia and palliative care providers. They will also fill out health-related quality of life surveys, including Functional Assessment of Cancer Therapy – Leukemia (FACT-Leu), Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire-9 (PHQ-9), and Satisfaction with Decision-Making Scale, at baseline, three, and six months. Main Outcome Measures: The primary outcome to be measured at completion of the study will be the feasibility of palliative care referral, defined as completion of the initial virtual consultation and at least 50% of the six scheduled monthly follow-up visits. Secondary outcomes will include the proportion of patients who complete the digital symptom questionnaires and the proportion of patients who complete their health-related quality of life surveys. Scores obtained from surveys will be used to generate hypotheses for future work. Despite recent lower-intensity therapies that have improved outcomes for older AML patients, AML remains associated with poor prognosis as well as high symptom burden. While the benefits of early palliative care and electronic PROs have been well-described in oncology patients, neither have been well-studied in AML, and they have never been studied in combination. To evaluate the feasibility of a virtually mediated supportive care model utilizing both electronic PROs and palliative care for patients with AML being treated with lower-intensity therapy (NCT04885127). This will be a prospective, single-arm, non-blinded trial with a year of enrollment and six months of follow-up. All patients will be enrolled at Stanford Comprehensive Cancer Center. We plan on enrolling 40 patients who are on first-line lower-intensity therapy for AML, defined as therapy that allows patients to receive care exclusively in the outpatient setting. Patients who are enrolled will be referred to the subspecialty palliative care clinic for virtual consultation and monthly follow-up visits for 6 months. Patients will also be instructed on the use of Noona, a digital application that allows real-time, remote monitoring of PROs. Patients will be requested to fill out a Noona symptom questionnaire prior to each palliative care visit and will be prompted to maintain a weekly symptom diary, which will be available to both their primary leukemia and palliative care providers. They will also fill out health-related quality of life surveys, including Functional Assessment of Cancer Therapy – Leukemia (FACT-Leu), Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire-9 (PHQ-9), and Satisfaction with Decision-Making Scale, at baseline, three, and six months. The primary outcome to be measured at completion of the study will be the feasibility of palliative care referral, defined as completion of the initial virtual consultation and at least 50% of the six scheduled monthly follow-up visits. Secondary outcomes will include the proportion of patients who complete the digital symptom questionnaires and the proportion of patients who complete their health-related quality of life surveys. Scores obtained from surveys will be used to generate hypotheses for future work.

What Do We Mean When We Ask for More Metastatic Breast Cancer Research?

Background: Almost all deaths from breast cancer are due to metastasis. People living with metastatic breast cancer (MBC) and their loved ones have been concerned about the lack of research progress. The purposes of this paper were to analyze breast cancer research spending in Canada, and to evaluate whether MBC research was aligned with patient priorities. The results from the MBC Priority Setting Partnership (MBC PSP) were used as an approximation of patient priorities. Methods: The data source was the Canadian Cancer Research Survey. MBC projects were identified and mapped to the patient priorities.Results: This analysis found that 18% of breast cancer research investment was directed to MBC, with a large proportion of this research investment focused on the biology of metastasis. Four of the top 10 MBC PSP priorities had not been addressed: optimal sequence of therapy, role of continuous versus intermittent treatment, benefits of early palliative care, and best methods for patient education. Conclusion: These figures provide a baseline from which any increases in MBC research and improved alignment to patient priorities can be measured. A cooperative effort by funders, researchers, patients, caregivers, and health care providers is needed to address research gaps.

Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care.

Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence. Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral. Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites. Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care. Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.

Palliative and Supportive Care in Neuro-oncology.

This article reviews the supportive care needs of patients with primary brain tumors and their caregivers, outlines the management of selected common symptoms of patients with brain tumors, and describes challenges and opportunities in providing palliative care for this population. Patients with primary malignant brain tumors generally have a poor prognosis and experience progressive neurologic decline and significant physical and psychological symptoms. Management of these symptoms, including fatigue, mood disorders, and the manifestations of cerebral edema, can be challenging. Caregivers for these patients have high rates of psychological distress and report significant caregiving burden. Although the benefit of early palliative care for patients with other advanced solid tumors is well established, our understanding of the role of palliative care in neuro-oncology is incomplete, and thus palliative care and hospice services remain underutilized. Patients with brain tumors and their caregivers have significant supportive care needs, which often differ from the needs of patients with cancers outside of the nervous system. Clinicians face challenges associated with managing patients' symptoms and adequately facilitating prognostic understanding and decision making. Palliative care and hospice services may offer important benefits for this population.

Modified Palliation in Cancer Patients during COVID-19 Pandemic

Corona virus disease 2019 (COVID 19) has put huge challenge to the health delivery system all across the globe. The risk of mortality due to COVID 19 is highest on critically ill patients and those with preexisting disease. Palliative and end of life care are no exceptions to the surge in increased demand for health care services. It is now an essential part of global health care. The benefits of early palliative care are already well established. In the pandemic like this, we must not pull back the services, particularly in these vulnerable groups. It is important to determine how best to deliver palliative care during this crisis. It may include preparedness to shift the focus of resources to community level and the innovative use of telemedicine. Use of telemedicine is to ease patients and minimize caregiver distress, and to prevent hospitalizations. The fear of contracting COVID-19 and the emotional burden during diagnosis requires the need of continuous psychosocial support. These challenges should be handled by specialized and skilled interdisciplinary palliative care team.

Associations Between the Intention to Use Early Palliative Care, Sources of Information, and Attitudes Toward a Good Death in Korean Adults

ContextProviding hospice and palliative care (HPC) early in the course of care for patients with life-threatening illness is important for improving patient quality of life. However, little literature exists for factors affecting to the intention to use early palliative care (EPC) of general population. ObjectivesThis study aimed to identify the sources of information about HPC, investigate whether they affect intention to use HPC and EPC, and examine the relationship between the components of a good death and the intention to use HPC and EPC. MethodsA stratified nationwide cross-sectional survey including 1500 participants, 20–74 years old, was conducted to investigate their intentions to use HPC and EPC, available information sources, and perceived components of a good death. ResultsThe main sources of information about HPC were television and radio. Information acquired from health professionals was positively associated with the intention to use EPC. Although regarding a good relationship with family as a component of a good death was related to low intention to use EPC, being able to trust medical staff, being involved in decisions about care, and being respected as an individual were associated with high intention to use EPC. ConclusionInformation from health care providers and public awareness through education and publicity efforts are necessary to inform the public about the benefits of EPC. Furthermore, it is essential that medical staff cultivate the skills necessary to secure public trust and provide care that respects patients until the end of their lives.

Characteristics and Impact of Post-Transplant Interdisciplinary Palliative Care Consultation in Older Allogeneic Hematopoietic Cell Transplant Recipients.

Context and Objectives: The myriad of benefits of early palliative care (PC) integration in oncology are well established, and emerging evidence suggests that PC improves symptom burden, mood, and quality of life for hematopoietic cell transplant (HCT) recipients. Specific impact of PC consultation on outcomes of older allogeneic HCT (allo-HCT) recipients, a historically high-risk population vulnerable to transplant-related complications and mortality, has not been explored. Design and Methods: In this single institution, retrospective analysis of 527 first allo-HCT recipients aged ≥60 years, we characterized 75 patients who had received post-HCT PC consultation and its association with geriatric vulnerabilities identified by pre-HCT geriatric assessment. We also examined end-of-life care outcomes among patients who died within one-year of allo-hematopoietic cell transplantation. Results: In multivariate analysis, higher disease risk, female gender, and, importantly, pre-HCT functional limitation (hazard ratio 2.35, 95% confidence interval, 1.35-4.09, p = 0.003) were associated with post-HCT PC utilization. Within one-year of hematopoietic cell transplantation, 127 patients died; among those, recipients of early PC consultation had significantly higher rates of hospice enrollment (25% vs. 9%, p = 0.019) and lower rates of hospital death (71% vs. 90%, p = 0.013), intensive care unit admission (44% vs. 75%, p = 0.001), and high-intensity medical care in last 30 days of life (46% vs. 77%, p = 0.001). Conclusions: Our results highlight important pre-HCT risk factors associated with increased PC needs posthematopoietic cell transplantation and benefits of PC involvement for older allo-HCT recipients at the end of life. Prospective studies should examine the optimal timing of PC consultation and its multidimensional benefits for older allo-HCT patients.

Multisite, Randomized Trial of Early Integrated Palliative and Oncology Care in Patients with Advanced Lung and Gastrointestinal Cancer: Alliance A221303.

Background: We conducted a multicenter, randomized trial of early integrated palliative and oncology care in patients with advanced cancer to confirm the benefits of early palliative care (PC) seen in prior single-center studies. Methods: We randomly assigned patients with newly diagnosed incurable cancer to early integrated palliative and oncology care (n = 195) or usual oncology care (n = 196) at sites through the Alliance for Clinical Trials in Oncology. Patients assigned to the intervention were expected to meet with a PC clinician at least monthly until death, whereas usual care patients consulted PC on request. The primary endpoint was the change in quality of life from baseline to week 12 per the Functional Assessment of Cancer Therapy-General (FACT-G). Secondary outcomes included anxiety, depression, and communication about prognosis and end-of-life care. Results: Due to significant morbidity and a high proportion of measures that were not completed within the protocol window or for unknown reasons, the rate of missing data was high. We anticipated that 70% of patients (n = 280) would complete the FACT-G at baseline and week 12, but only 49.3% (n = 193/391) completed the measure. Delivery of the intervention was also suboptimal, as 14.9% (n = 29/195) of intervention patients had no PC visits by week 12. Intervention patients reported a mean 3.35 (standard deviation [SD] = 14.7) increase in FACT-G scores from baseline to week 12 compared with usual care patients who reported a 0.12 (SD = 12.7) increase from baseline (p = 0.10). Conclusion: This study highlights the difficulties of conducting multicenter trials of supportive care interventions in patients with advanced cancer. Clinical Trials Registration: NCT02349412.

The impact of early palliative care on the quality of life of patients with advanced pancreatic cancer: The IMPERATIVE study.

TPS777 Background: Pancreatic cancer is lethal. Chemotherapy can improve survival by months; however, many patients experience an overwhelming burden of cancer-associated symptoms and poor quality of life (QOL). Early palliative care (EPC) alongside standard oncologic care results in improved QOL and survival in patients with lung cancer. Although international guidelines recommend EPC for patients with advanced pancreatic cancer (PANC), the benefit is not known. Objectives: The primary objective is to test for change in QOL between baseline (BL) and 16 weeks (wk). Secondary objectives are to test for change between BL and 16 wk in (a) symptom control; and (b) depression and anxiety. Methods: This prospective case-crossover study of patients with PANC provides EPC plus standard oncologic care. Primary oncology clinics refer patients to an EPC team led by a palliative care physician and a clinical nurse specialist. BL questionnaires are completed prior to initial EPC assessment, then every 4 wk until wk 16. EPC visits are every 2 wk for the first month, every 4 wk until wk 16, and then as needed. QOL, symptom control, anxiety and depression are measured using the FACT-Hep tool, ESAS-r, HADS and PHQ-9, respectively. A generalized linear model will test for statistically significant change in scores between BL and 16 wk; chemotherapy (yes/no) is included as a confounding covariate; model fit will be assessed. A sample size of 20 patients provides 80% power after controlling for covariate effects. 40 patients will be enrolled to account for missing data. To date, 28 patients have enrolled and 17 have completed the intervention. Significance: The benefit of EPC for patients with PANC is not known, however, EPC is increasingly recognized internationally by patients and stakeholders as a critical intervention which may improve both QOL and satisfaction with care. The Canadian Partnership Against Cancer’s report on the patient experience states “the best possible patient experience means all people with cancer have equitable access to high-quality person-centered palliative care”. This study offers access to EPC and provides an environment in which the benefit of an integrated approach is evaluated.

A Quality Improvement Project to Provide Early Referral to Palliative Care Clinic for Advanced Oral Cancer Patients (TH341A)

•Identify palliative care needs, referral timings and reasons for delay in referral to palliative care clinic for advanced oral cancer patients.•Develop, test and sustain interventions to provide early referral to palliative care clinic for advanced oral cancer patients. Recent literature affirms the benefits of early palliative care in advanced cancer patients. The prevalence of oral cancer is high in India and often patients present at advanced stages at the time of diagnosis. Bleak scope of curative treatment and high symptomatic burden detracts from the quality of life of these patients. The aim of this study was to provide early referral to a palliative care clinic for advanced oral cancer patients. This initiative was carried out at Dr B. R. Ambedkar, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, India in collaboration with quality improvement leaders at Stanford University. A multidisciplinary team consisting of oncologists, surgeons, nurses, administrative staff, palliative care physicians and overseas quality improvement mentors was formed. Using A3 methodology, we applied improvement tools to understand the current situation. A cause and effect analysis revealed absence of referral guidelines and misalignment of what was deemed appropriate early referral as the major factors contributing to the practice of late referral. Our interventions were developing a standard, agreed upon, protocol for providing palliative care referral and consultation, creating awareness through pamphlets, educating oncologists and surgeons through weekly departmental meetings and documenting symptom burden in the medical record. The interventions were sustained by soliciting feedback from oncologists and surgeons during periodic departmental meetings, educating new oncologists and surgeons about referral protocols during their orientation program i.e. once in three months and by auditing patient referral data. Number of days from identification of advanced oral cancer to referral to palliative care clinic decreased from an average of 48 days at baseline to 13 days post-interventions. Early referrals to palliative care clinic are possible using a multidisciplinary team approach focusing on aligning expectations between oncologists, surgeons and palliative care professionals, modifying process maps and standardizing and documenting assessment.

Integrating early palliative care into routine practice for patients with cancer: A mixed methods evaluation of the INTEGRATE Project.

With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys. A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified. A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support.

“It’s not Magic, It’s Intentional Communication”—Using the Primary Palliative Care Communication Toolkit to Teach Communication to Interdisciplinary Learners at Different Levels of Training (FR453)

•Incorporate literature-based fundamental conceptual frameworks in communication into a workable toolkit for “just in time” use, for the right learner at the right time at the right place.•Develop a personalized skill set for Palliative Care teams to recognize teachable moments in everyday care and disseminate timely and concise teaching pearls in communication using the Toolkit.•Identify techniques to incorporate primary palliative care communication instruction to enhance skill sets in non-palliative care trainees and inter-professional learners. Primary palliative care (PPC) instruction is gaining prominence as benefits of early palliative care (PC) become clear, as patients live longer with serious illness, and as hospital systems look to improve the care of medically frail patients. With the growth of academic PC, the opportunity to engage learners of many disciplines and levels of training has expanded. Effective PC is based on excellent communication, which can be challenging to teach, especially in busy clinical practices. We discuss the interdisciplinary PC faculty skills development in utilizing the flexible and adaptable PPC Communication Toolkit. We demonstrate how our current training curriculum for fellows and other learners of various levels and disciplines incorporate this Toolkit to enable learners to build on their personal frame of reference as they see faculty incorporate these principles and techniques into everyday practice. Attendees will apply and practice these core elements, methodologies and techniques to engage both teachers and learners during the session. We will showcase four ways the Toolkit has been adapted and incorporated into communication training at a large academic institution and VA hospital. During a real-time consult PC faculty apply the “catch and release” method to coach learners on non-PC rotations when a PC consult is requested. PC faculty use the Toolkit to teach advance care planning to Nephrology fellows, to structure goals of care discussions with Internal Medicine residents on a geriatrics rotation, and to coach ICU nurse practitioners. The Primary Palliative Care Communication Toolkit is a creative, consistent, and adaptable way to incorporate communication training into the day-to-day care of patients living with serious illness and into the education of learners of different disciplines and levels of training. Participants will find tools and ideas that are easy and fun to use as they teach the next generation of clinicians to care for seriously ill patients.