End-of-life Care Discussions Research Articles

Factors affecting advance care planning in older adults with cancer

IntroductionAdvance care planning (ACP) has been widely endorsed and recommended for its many potential benefits, including improved end-of-life (EOL) care, enhanced satisfaction with care, and reduced anxiety and depression. However, little is known about the ACP completion rates and factors affecting ACP among older adults with cancer. This study's purpose was to examine biological, psychological, and social factors affecting ACP in this population. Materials and MethodsData from the 2002 to 2016 waves of exit interviews from the national longitudinal Health and Retirement Study were analyzed. The sample included 1088 decedents, aged 55 and over, who had a diagnosis of cancer. The exit interviews were completed by a proxy respondent (usually the next of kin of the decedents). ACP outcomes included: having EOL care discussion, durable power of attorney (DPOA), and advance directives (ADs). Multiple logistic regression models were conducted to examine the relationships between predictor variables and each of the three ACP outcome variables. ResultsApproximately 65% of the sample had ever discussed EOL care, 61.9% had an assigned DPOA, and 54.1% had ADs. Regression results showed that higher age, Black race, high school and above education, being widowed/never married, higher multimorbidity, and more limitations in activities of daily living and instrumental activities of daily living were significantly associated with the three ACP variables. Surprisingly, Black race was associated with higher odds of ever discussing EOL care and having ADs; high school and above education was associated with lower odds of all three ACP components. DiscussionThe majority of participants in this study had discussed EOL care, had an assigned DPOA, and had ADs. However, most participants were White/Caucasian and had completed high school education. Future research that includes more diverse and minoritized participants is needed. Also, the contrasting association of Black race and higher educational status with ACP outcomes warrant further exploration in future studies.

Multi-site randomized trial of a collaborative palliative and oncology care model for patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) receiving non-intensive therapy.

LBA6508 Background: Patients with AML and high-risk MDS receiving non-intensive chemotherapy have substantial quality of life (QOL) impairments and often do not engage in timely discussions with their clinicians about their end-of-life (EOL) care preferences. Yet interventions to optimize EOL care delivery and QOL for this population are lacking. Methods: We conducted a multi-site randomized clinical trial of a collaborative palliative and oncology care model compared to usual care in 115 adult patients with AML and high-risk MDS receiving non-intensive therapy at two tertiary care academic hospitals. Patients with a new diagnosis or relapse/ refractory disease were eligible to participate within 30 days of initiating therapy. Patients assigned to the intervention met with a palliative care clinician monthly in the outpatient setting and a minimum of twice weekly during every hospital admission. Patients assigned to usual care were seen by palliative care only upon request. We used Natural Language Processing methods to interrogate the Electronic Health Record (EHR) with a validated algorithm to collect documented EOL care preferences. The primary outcome was to compare time from documentation of EOL care preferences to death between the study arms. Secondary outcomes obtained from the EHR include rates of documentation of EOL care preferences, hospitalization, and hospice utilization at the EOL. Patient-reported secondary outcomes include discussions with clinicians about EOL care preferences, QOL (Functional Assessment of Cancer Therapy – Leukemia), and psychological distress (Hospital Anxiety and Depression Scale) at 3 months after enrollment. Results: We enrolled 51.8% (115/222) of eligible patients. The rate of documented EOL care discussions in the EHR was higher among intervention patients vs. usual care (96.5% vs. 68.4%, P<0.001). Overall, 61.7% (71/115) of patients died, and those receiving the intervention had a longer time from documentation of EOL care preferences to death (41 days vs. 1.5 days, P<0.001). Intervention patients were more likely to report discussing their EOL care preferences with their clinicians (56.9% vs. 14.0%, P<0.001), and less likely to be hospitalized in the last 30 days of life (70.6% vs. 91.9%, P=0.031). There was no difference in hospice utilization at the EOL. At 3 months, patients assigned to the intervention reported better QOL (138.6 vs. 125.5, P=0.010), but no difference in depression or anxiety symptoms compared to those assigned to usual care. Conclusions: Palliative care significantly improved rates of discussion and documentation of EOL care preferences, reduced hospitalization at the EOL, and improved QOL in patients with AML and high-risk MDS. Clinical trial information: NCT03310918 .

Knowledge and Attitudes of Allied Health Professionals Towards End-Of-Life and Advance Care Planning Discussions With People With COPD: A Cross-Sectional Survey Study.

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting condition. End-of-life (EOL) and Advance Care Planning (ACP) discussions are essential, yet access and support remain inadequate. Allied health professionals (AHPs) commonly have ongoing relationships with patients and opportunities to discuss care outside acute crises as is considered best practice. Australian and New Zealand AHPs were invited to complete an anonymous, online, cross-sectional survey that aimed to explore knowledge, attitudes and practices, and associated perceived triggers and barriers to EOL and ACP discussions with patients with COPD. Closed survey responses were summarized descriptively and free-text thematically analysed. One hundred and one AHPs (physiotherapists, social workers and occupational therapists) participated. Many held positive attitudes towards ACP but lacked procedural knowledge. Half (50%) of participants routinely discussed EOL care with patients when perceiving this to be appropriate but only 21% actually discussed ACP with the majority of their patients. Many cited lack of training to engage in sensitive EOL discussions, with barriers including: 1) clinician lack of confidence/fear of distressing patients (75%); 2) perceived patient and family reluctance (51%); 3) organizational challenges (28%); and 4) lack of role clarity (39%). AHPs commonly have ongoing relationships with patients with chronic conditions but lack the confidence and role clarity to utilise this position to engage ongoing EOL and ACP discussions. While AHPs may not traditionally consider EOL and ACP discussions as part of their role, it is crucial that they feel prepared to respond if patients broach the topic.

A Novel Curriculum to Improve Medical Student Preparedness to have Advance Care Planning Discussions.

Background: Physicians report inadequate training in advance care planning (ACP) discussions despite the importance of these skills for practicing physicians including new residents. Objectives: To evaluate the effectiveness of a novel curriculum to prepare graduating medical students to have ACP discussions. Design: An ACP curriculum was implemented within a new fourth-year medical student elective with a focus on interactive educational methods and simulated experiences. Setting/Subjects: Forty-seven students received the curriculum over 3years at a medium-sized, urban medical school. Measurements: Students were surveyed regarding attitudes and comfort related to ACP discussions and end-of-life (EOL) topics before and after the course. Additionally, students were asked about baseline experiences in the pre-course survey and perceived effectiveness of the educational methods in the post-course survey. Results: Comfort discussing EOL care decisions without supervision rose from 4% to 36% after the course with none of the students feeling they needed maximal help from a supervisor after the course compared to 51% before the course. All students agree or strongly agreed (Likert 4 or 5) that they felt prepared to discuss patient's wishes and values in EOL care with a real patient or family after the course. Conclusions: An ACP curriculum can increase student comfort and preparedness to have these conversations as residents. Students found small group discussions and the chance for direct practice with simulated patients to be most helpful. These findings can help guide implementation of ACP curricula in medical education.

Medical oncologists' perspectives of end-of-life care communication with racial/ethnic minority and limited English proficiency patients.

e18585 Background: Racial/ethnic minority (REM) and limited English proficiency (LEP) patients with cancer receive more intensive treatment at the end-of-life (EOL) compared to non-Hispanic whites. Various factors at the health system, patient, and provider level contribute to this disparity. While some data exists on the role of provider communication, little is known about medical oncologists' knowledge and attitudes regarding EOL care communication with REM and LEP patients with cancer. Methods: We conducted a cross-sectional, anonymous, pilot survey of medical oncology attendings and fellows at one academic center. Over 3 months, 57 individuals were invited to participate. The survey addressed 6 domains about EOL care communication with REM and LEP patients (role of language, barriers, facilitators, provider beliefs, provider communication skills, and cultural competency training). Questions used Likert scales and were modified from previously validated items when possible. Results: Of 35 individual respondents (61% response rate) 21 (60%) were male, 14 (40%) were female, and 29 (83%) were attendings. Average participant age was 42 years (range 31-60 years) and average years in practice was 9 (range 2-25 years). Twenty-three (66%) self-identified as non-Hispanic white, 11 (31%) as Asian, and 1 (3%) as other. Thirty-three (94%) reported their primary language as English and 23 (66%) reported speaking a second language. A majority (77%) strongly agreed discussing EOL care is part of an oncologist’s job and 69% strongly agreed patients with cancer, regardless of race/ethnicity or English language ability, should be engaged in EOL care discussions. Among several facilitators identified, two most highly rated as “Very Important” were eliciting patient belief systems about their disease (71%) and about death/dying (69%). However, only 14% strongly agreed they ask patients their beliefs about death/dying, and a minority strongly agreed they feel comfortable having EOL care discussions with REM (34%) and LEP (29%) patients. Importantly, 77% rated themselves at 6 or 7 (on a scale from 0 to 10, with 10 being the best) in how well they currently communicate about EOL care with REM and LEP patients, 74% reported wanting to be at 8 or 9 in 6 months, and 89% completely or somewhat agreed with wanting help to improve. Conclusions: Our results suggest there is conceptual understanding among academic medical oncologists of the need to engage all patients in EOL care discussions and elicit patient belief systems on the topic. Though there is lack of comfort in having EOL care discussions with REM and LEP patients, and infrequent inquiry about patient belief systems, there is also motivation to improve communication skills in this area. Interventions that foster medical oncologists' comfort and skills in cross-cultural, language non-congruent communication about EOL care are needed.

Differences in Attitude towards End-Of-Life Care among Haemodialysis Patients and their Family Members in Two Malaysian Hospitals

INTRODUCTION: End-of-life (EOL) care has become an important topic of discussion in those with chronic illness, especially in End Stage Renal Disease (ESRD) patients on dialysis. This study explored attitudes towards the EOL care among haemodialysis patients and compared them with the patients’ family members. MATERIALS AND METHODS: The study was a cross-sectional descriptive study conducted in two tertiary hospitals in Malaysia. The data was collected by using a survey questionnaire from 164 participants which consisted of 82 pairs of patients and their relatives. RESULTS: ‘Patient’ and ‘family’ groups demonstrated differences in their preferences regarding EOL care options. Family members group favoured cardiopulmonary resuscitation (81.7% vs 41.4%) (p <0.001), endotracheal intubation (80.5% vs 43.9%) (p = 0.989) and nasogastric tube feeding (87.8% vs 67%) (p = 0.001) more than patients themselves. The physician was the most nominated surrogate decision-maker by the patient (91.5%). Majority of the patients (57.3%) felt uncomfortable discussing EOL care options. There was significant correlation between duration of dialysis and patients’ EOL preferences where patients less than 5 years on haemodialysis favoured CPR (55.9% vs 31.3%; p = 0.026), intubation (55.9% vs 35.4%) and nasogastric tube feeding (82.3% vs 56.3%; p = 0.013) compared to patients who had been on haemodialysis for 5 years or longer. CONCLUSION: This study demonstrated significant differences between the attitudes of the patients and their relatives regarding EOL care preferences.

Trends in advance care planning and end-of-life care among persons living with dementia requiring surrogate decision-making.

Previous studies have demonstrated positive impacts of advance care planning (ACP) on end-of-life (EOL) care. We sought to examine trends in ACP and EOL care intensity among persons living with dementia who required surrogate decision-making in their final days of life. We analyzed the participants of the Health and Retirement Study (HRS), a nationally representative longitudinal panel study of U.S. residents, with dementia 70 years and older who required surrogate decision-making in the final days of life and died between 2000 and 2014. Based on surrogate reports after the death of a participant, our study measured the completion of three specific types of patient-engaged ACP (written EOL care instructions, assignment of a durable power of attorney for healthcare, patient engagement in EOL care discussions) and four measures of EOL care in the final days of life (death in hospital, receipt of life-prolonging treatments, limiting or withholding certain treatments, and receipt of comfort-oriented care). All analyses accounted for the complex survey design of HRS. Among 870 adults (weighted N= 2,812,380) with dementia who died in 2000-2014 and required surrogate decision-making at EOL, only 34.8% of patients participated in all three aspects of ACP, and there was not a significant increase in ACP completion between 2000 and 2014. The receipt of life-prolonging treatments in the final days of life has increased over time (adjusted change per year, 1.4 percentage points [pp]; 95% CI, 0.5 to 2.2pp; P-for-trend=0.002), while the percentage of death in hospital, limiting or withholding certain treatments, or comfort-oriented care did not change. Our findings suggest that the rates of ACP completion have not increased over time despite its potential benefits and life-prolonging treatments are still common among PLWD who require surrogate decision-making, a population who might benefit greatly from early ACP.

Randomized Trial of a Palliative Care Intervention to Improve End-of-Life Care Discussions in Patients With Metastatic Breast Cancer.

Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population. Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization. The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21-7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10-14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms. This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories. ClinicalTrials.gov identifier: NCT02730858.

Family Conflict and Older Chinese Americans’ Self-Efficacy in End-of-Life Care Planning: The Role of Acculturation

Objectives: Under-reporting of unemployment or forced retirement has consequences for measuring the impacts of job changes on health at retirement. We analyzed a comprehensive three-part measure of lost work opportunity for evidence of impact on health.Methods: We combined variables from the Health and Retirement Study for 2,576 respondents assessing unemployment, forced retirement, and earlier than planned retirement into a single lost work opportunity score (LOS). We evaluated the reliability and unidimensionality of the LOS. We conducted multivariate regression to assess health impacts controlling for age, gender, education, race, ethnicity, and prior health status.Results: The Cronbach’s Alpha for the LOS was a = 0.76 and the LOS variables primarily loaded onto a single component demonstrating undimensionality. The LOS significantly predicted self-reported health (□= .16; p < .001) with higher lost work associated with negative health outcomes (Cox and Snell R2 = 0.07). The LOS score significantly predicted mental health declines (□ = .07; p = .002)(Cox and Snell R2 = 0.07).Discussion: Population-level data indicates that health declines following both unemployment and retirement, but there is ample evidence that early or planned retirements do not show the same negative health impacts. We examined the health impact of retirement using the construct of lost work opportunity rather than voluntary or involuntary retirement, per se. Our findings indicate that as much as 7% of negative health changes in the early retirement years could be attributable to employment changes that were unplanned or experienced as outside the retiree's control.

Family Conflict and Older Chinese Americans’ Self-Efficacy in End-of-Life Care Planning: The Role of Acculturation

Family involvement in end-of-life (EOL) care is critical to ensure older adults’ health and quality of life. Older adults’ self-efficacy in discussing EOL care plans with family members can facilitate family involvement in EOL care planning. Research shows that family relationships are associated with self-efficacy in discussing EOL care with family members among older Chinese Americans. However, the roles of family conflict and acculturation remain unknown. This study examines the association between family conflict and self-efficacy in discussing EOL care with family members and whether such an association differs by acculturation levels among older Chinese Americans. Data were collected from 207 Chinese Americans aged 65-102 in two metropolitan areas in 2017. Ordinary least squares regression was conducted to examine the association between family conflict, acculturation, and self-efficacy in discussing EOL care with family. Family conflict was negatively associated with older adults’ self-efficacy in discussing EOL care with family. More specifically, the negative association between family conflict and self-efficacy in discussing EOL care with family members was more pronounced for those with higher levels of acculturation. Findings highlighted differential effects of family conflict on self-efficacy of EOL care plan discussion for older adults with different acculturation levels. Those with higher acculturation may be more independent in their EOL care planning and aware of the possible negative effects of family conflict in their EOL care planning discussions. Acculturation needs to be considered by geriatric health providers to develop family-centered interventions in improving end-of-life care planning for this population.

Exploratory Study of Advance Care Discussions Among Chinese American and White Stage IV Cancer Patients at an American Tertiary Medical Center.

Timely advance care discussions are essential components of quality care for diverse populations; however, little is known about these conversations among Chinese American cancer patients. This exploratory study describes differences in advance care discussions and planning between Chinese American and White advanced cancer patients. We collected data for 63 Chinese American and 63 White stage IV cancer patients who died between 2013 and 2018. We compared: frequency and timing of prognosis, goals of care (GOC), and end-of-life care (EOLC) discussions in the final year of life; family inclusion in discussions; healthcare proxy (HCP) identification; do not resuscitate (DNR) order, do not intubate (DNI) order, and other advance directive (AD) completion. We did not conduct statistical tests due to the study's exploratory nature. Among Chinese American and White patients, respectively, 76% and 71% had prognosis, 51% and 56% had GOC, and 89% and 84% had EOLC discussions. Prognosis, GOC, and EOLC discussions were held a median of 34.0, 15.5, and 34.0 days before death among Chinese American and 17.0, 13.0, and 24.0 days before death among White patients. Documentation rates among Chinese American and White patients were 79% and 76% for DNRs, 81% and 71% for DNIs, 79% and 81% for HCPs, and 52% and 40% for other ADs. Findings suggest that Chinese Americans had similar rates of advance care discussions, completed conversations earlier, and had similar to higher rates of AD documentation compared to White patients. Further studies are needed to confirm our preliminary findings.

Attitude Toward Family Involvement in End-of-Life Care Among Older Chinese Americans: How Do Family Relationships Matter?

Family involvement is critical to end-of-life (EOL) care among older adults. This study aims to examine the association and pathways between family relationships and older Chinese Americans' attitude toward family involvement in EOL care discussions. Data were collected from 260 Chinese Americans aged 55 years and above. Structural equation modeling was used to examine the total and indirect effects of family relationships on attitude toward family involvement in discussing EOL care plans. Family relationships had a significant positive total effect on attitude toward family involvement in EOL care. Indirect effects of family relationships on attitude toward family involvement in EOL care through self-efficacy, perceived benefits, and perceived barriers of discussing EOL care with family members were all significant. Findings provide empirical evidence of how family relationships affect older Chinese Americans' attitude toward family involvement in EOL care and underline the need for family-centered EOL interventions for this population.

P0444 / #698: IDENTIFYING EXPERIENCES, ATTITUDES AND PRACTICES AROUND THE LIMITATION OF TREATMENT AGREEMENT (LOTA) DECISIONS AMONG PAEDIATRIC PROFESSIONALS IN THE YORKSHIRE AND HUMBER REGION, UK.

Aims & Objectives: Aims: To identify the learning needs of the paediatric professionals in the Yorkshire and Humber region, UK with regards to having the end of life care discussions and documentation of limitation of treatment agreements. Objectives: To investigate the opinions of paediatric health professionals, both doctors and nurses, as to when it is appropriate to have a discussion regarding end of life decisions and limitation of treatment agreements with parents of children with known life-limiting and life-threatening conditions. Methods: We collected the opinions of paediatric health care professionals (doctors from all grades, and nurses) using a questionnaire and clinical vignettes through an online survey website, Survey Monkey. Results: Survey results collected from a varied group of participants showed that even though participants felt the LOTA should be discussed and family’s views should be sought and documented during three clinical vignettes, in their experiences, these discussions are happening much less frequently. Also, most participants didn’t feel comfortable having these discussions. Conclusions: Survey results collected from a varied group of participants showed that even though participants felt the LOTA should be discussed and family’s views should be sought and documented during three clinical vignettes, in their experiences, these discussions are happening much less frequently. Also, most participants didn’t feel comfortable having these discussions.

Implementing Advance Care Planning in 'The Age of Deferred Death'- the Hong Kong Experience over 4 Years.

ObjectivesTo plan, implement and evaluate a series of initiatives to improve patient centred quality of end of life care through raising public awareness, promoting the concept that all health and social care professionals should be engaged in this practice, and carrying out pilot of community care models.DesignPilot studies of community models of care, training programs for health and social care professionals, public education programmes.SettingSelected hospitals, residential care homes for the elderly, and community centres in Hong Kong.ParticipantsPatients and their families at the end of life stage.MeasurementsCombination of quantitative and qualitative studies according to different components of the initiative.ResultsEffective training for professional staff occurred using training videos, role play, rather than lectures, and when concepts are integrated into daily practice and quality assurance programmes. Members of the public welcomed end of life care discussions and the implementation of advance care planning. The pilot community care program was found to reduce anxiety, depression, physical symptoms, improve communication within the family as well as promoting a feeling of peace among recipients of the service. It also reduced care giver strain and anxiety, as well as hospital visits and duration of stay. Similar findings were also observed among recipients of care in the residential care setting.ConclusionA sustainable model would require uptake by policy makers and chief executives of Social Welfare and Health Bureaus, supported by amendments of relevant legal ordinances, which is in progress after public consultation.

Impact on Self-Efficacy on End of Life Care Discussions: Before and after Structured Educational Training on Licensed Nurses

Nurses played an essential role in initiating end of life care discussions. Initiating advance discussions on end of life care options provides the patient and family the opportunity to start the process of preparing and planning end of life care. The discussions included choosing options specific to their own needs, goals, wishes, and preferences. Research studies findings demonstrated an evident lack of end of life care discussions and advance care planning initiation by nurses because of reported lack of education, training, and skills in this topic. The following DNP project used a quantitative, comparative, quasi-experimental before and after design to evaluate changes in the licensed nurses' self-efficacy in conducting end of life care discussions. The Advance Care Planning Self-Efficacy Scale was used to compare the licensed nurses' self-efficacy in conducting end of life care discussions before and after completing a structured educational activity. The data collected from the surveys were analyzed using a Wilcoxon Signed Rank Test matched-pair revealed a statistically significant change in advance care planning self-efficacy scores following completion of the structured educational training on end of life care discussions. The DNP project findings demonstrated that structured education that includes allowing licensed nurses to practice end of life care conversations improved licensed nurses' self-efficacy in conducting these conversations, filling a gap in the research literature. A further research study that measures the frequency of licensed nurses' holding end of life care conversation will be beneficial for future research.

Impact of palliative care on end-of-life care and place of death in children, adolescents, and young adults with life-limiting conditions: A systematic review.

To determine the impact of palliative care (PC) on end-of-life (EoL) care and the place of death (PoD) in children, adolescents, and young adults with life-limiting conditions. Eight online databases (PubMed, Medline, EMBASE, Cochrane Library, CINAHL, Airiti, GARUDA Garba Rujukan Digital, and OpenGrey) from 2010 to February 5, 2020 were searched for studies investigating EoL care and the PoD for pediatric patients receiving and not receiving PC. Of the 6,468 citations identified, 14 cohort studies and one case series were included. An evidence base of mainly adequate- and strong-quality studies shows that inpatient hospital PC, either with or without the provision of home and community PC, was found to be associated with a decrease in intensive care use and high-intensity EoL care. Conflicting evidence was found for the association between PC and hospital admissions, length of stay in hospital, resuscitation at the time of death, and the proportion of hospital and home deaths. Current evidence suggests that specialist, multidisciplinary involvement, and continuity of PC are required to reduce the intensity of EoL care. Careful attention should be paid to the need for a longer length of stay in a medical setting late in life, and earlier EoL care discussion should take place with patients/caregivers, especially in regard to attempting resuscitation in toddlers, adolescents, and the young adult population. A lack of robust evidence has identified a gap in rigorous multisite prospective studies utilizing data collection.

Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia

Patients with acute myeloid leukemia (AML) receiving intensive chemotherapy experience substantial decline in their quality of life (QOL) and mood during their hospitalization for induction chemotherapy and often receive aggressive care at the end of life (EOL). However, the role of specialty palliative care for improving the QOL and care for this population is currently unknown. To assess the effect of integrated palliative and oncology care (IPC) on patient-reported and EOL outcomes in patients with AML. We conducted a multisite randomized clinical trial of IPC (n = 86) vs usual care (UC) (n = 74) for patients with AML undergoing intensive chemotherapy. Data were collected from January 2017 through July 2019 at 4 tertiary care academic hospitals in the United States. Patients assigned to IPC were seen by palliative care clinicians at least twice per week during their initial and subsequent hospitalizations. Patients completed the 44-item Functional Assessment of Cancer Therapy-Leukemia scale (score range, 0-176) to assess QOL; the 14-item Hospital Anxiety and Depression Scale (HADS), with subscales assessing symptoms of anxiety and depression (score range, 0-21); and the PTSD Checklist-Civilian version to assess posttraumatic stress disorder (PTSD) symptoms (score range, 17-85) at baseline and weeks 2, 4, 12, and 24. The primary end point was QOL at week 2. We used analysis of covariance adjusting and mixed linear effect models to evaluate patient-reported outcomes. We used Fisher exact test to compare patient-reported discussion of EOL care preferences and receipt of chemotherapy in the last 30 days of life. Of 235 eligible patients, 160 (68.1%) were enrolled; of the 160 participants, the median (range) age was 64.4 (19.7-80.1) years, and 64 (40.0%) were women. Compared with those receiving UC, IPC participants reported better QOL (adjusted mean score, 107.59 vs 116.45; P = .04), and lower depression (adjusted mean score, 7.20 vs 5.68; P = .02), anxiety (adjusted mean score, 5.94 vs 4.53; P = .02), and PTSD symptoms (adjusted mean score, 31.69 vs 27.79; P = .01) at week 2. Intervention effects were sustained to week 24 for QOL (β, 2.35; 95% CI, 0.02-4.68; P = .048), depression (β, -0.42; 95% CI, -0.82 to -0.02; P = .04), anxiety (β, -0.38; 95% CI, -0.75 to -0.01; P = .04), and PTSD symptoms (β, -1.43; 95% CI, -2.34 to -0.54; P = .002). Among patients who died, those receiving IPC were more likely than those receiving UC to report discussing EOL care preferences (21 of 28 [75.0%] vs 12 of 30 [40.0%]; P = .01) and less likely to receive chemotherapy near EOL (15 of 43 [34.9%] vs 27 of 41 [65.9%]; P = .01). In this randomized clinical trial of patients with AML, IPC led to substantial improvements in QOL, psychological distress, and EOL care. Palliative care should be considered a new standard of care for patients with AML. ClinicalTrials.gov Identifier: NCT02975869.

Discussions Between People With Dementia and Care Partners About End-of-Life Care Planning

Advanced care planning (ACP) leads to better end-of-life (EoL) care. Yet, some care-partners are unaware of the person with dementia’s (PwD) preferences. Care-partners play an important role in urging PwD to consider their EoL care wishes early in their disease course and to document those wishes. However, it is unknown whether discussions between care-partners and PwD are associated with documenting EoL care plans. We apply generalized linear models to baseline data from the CARE-IDEAS study which includes a sample of patients who received an amyloid PET scan and their care-partners (n=1,672). We examine the association between PwD report of having discussed EoL care with their care-partner and PwD report of having documented their plans through an advanced directive, a living will, or designating a health care proxy. PwD who reported speaking with their care-partners about EoL care were 10% (marginal probability (MP) 0.10; 95% CI: 0.8, 0.13) more likely to have documented their EoL care wishes. Furthermore, if PwD and care-partners agreed that they had discussed EoL care, PwD were 7% (MP 0.7; 95% CI 0.04, 0.10) more likely to report that they documented their EoL care plans. The positive association between communicating with care-partners about EoL care and having formal EoL care plans suggests that the ACP process could be a systematic approach to increase the care-partner’s knowledge of PwD EoL wishes. These results also suggest that increasing involvement of care partners in ACP may encourage patients to document their wishes at end of life.

Attitude Toward Family Involvement in End-of-Life Care Among Older Chinese Americans

Family involvement is critical to end-of-life (EOL) care of older adults. Attitude toward family involvement in EOL care can be influenced by family relationship. Yet, mechanisms explaining such influence have not been examined among older Chinese Americans. This study aims to examine the association between family relationship and older Chinese Americans’ attitude toward family involvement in EOL care and explore pathways of this association. Potential mediators include self-efficacy, perceived benefits, and perceived barriers of discussing EOL care with family members. Data were collected from 276 Chinese Americans aged 55+ in two metropolitan areas in 2018. Participants’ average age was 74 years (SD=9.6). Approximately 64% of the sample were female. Most participants (57%) held positive attitudes toward family involvement in EOL care. Using the Structural Equation Modeling method, we found that family relationship had a significant positive total effect on positive attitude toward family involvement in EOL care (z=5.57, p<0.001). Indirect direct of family relationship on attitude toward family involvement in EOL care through both self-efficacy (z=3.13, p<0.01) and perceived barriers (z=2.30, p<0.05) of discussing EOL care with family members was significant. Results suggest that improving family relationship may increase elder’s self-efficacy and reduce barriers of discussing EOL with family members, which is associated with more positive attitude toward family involvement in EOL care. Findings provide empirical evidence of how family relationship affects older Chinese Americans’ attitude toward family involvement in EOL care and underline the need for family-centered interventions for older Chinese Americans.

Oncologic Emergencies: Palliative Care in the Emergency Department Setting.

Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL). This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain. As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL. Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.