Care In Last Month Research Articles

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.

Palliative Care and End-of-Life Outcomes Following High-risk Surgery

Palliative care has the potential to improve care for patients and families undergoing high-risk surgery. To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included. Palliative-care consultation within 30 days before or 90 days after surgery. The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery. Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

How is KRAS testing associated with treatment and supportive care for patients with metastatic colorectal cancer? VA national assist project.

64 Background: EGFR monoclonal antibody (mAb) therapies improve quality of life and outcomes for metastatic colorectal cancer (mCRC), but only wild-type KRAS benefit from treatment. We evaluated KRAS testing and pharmacogenetic-guided treatment and supportive and end of life (EOL) care. Methods: Among a national random sample of 265 veterans diagnosed with mCRC in 2008 we evaluated KRAS testing, EGFR mAb therapy, supportive care using the Cancer Quality ASSIST indicators, and healthcare use. Three oncology nurses abstracted charts for care received 2008-2011. We linked chart to VA and Medicare administrative data and compared care received by KRAS testing and results. Results: 227/265 (85%) veterans died within 3 years and received an average of 48% of recommended supportive care processes. 96 / 265 (36%) underwent KRAS testing, of whom 41, 42, and 13 had wild-type, mutant, and indeterminant/unknown KRAS. 27/41 (66%) wild-type KRAS patients received an EGFR mAb; 18/45 (40%) patients receiving an EGFR mAb had mutant, indeterminant/unknown, or untested KRAS. KRAS testing was associated with increased systemic therapy but not differences in supportive care or intensity of care at the EOL. KRAS tested vs. not tested received hospice or palliative care (67 vs. 73%, p=0.55); any systemic therapy (96 vs. 40%, p<0.001) including new regimen in last month (0 vs. 6%); any chemotherapy in last 14 days of life (9 vs. 7%); and any acute care in last month of life (28 vs. 32%, p=0.78). Conclusions: KRAS testing was not performed for most veterans with mCRC in 2008, and EGFR mAb therapy was administered to many without wild-type KRAS. KRAS-tested patients were more likely to receive systemic treatments, and testing was not associated with greater intensity or inappropriate EOL care, and rates of such care were low among veterans.