Early Palliative Care Involvement Research Articles

Early palliative care involvement in gastrointestinal malignancies: A community cancer center perspective.

198 Background: Early involvement of palliative care (PC) specialists enhances quality of life for patients with advanced gastrointestinal (GI) cancer. Methods: This retrospective study evaluated patients with newly diagnosed stage III and IV GI cancer seen at a large community cancer center between 10/1/22 and 9/30/23. We compared patients seen by a PC provider in clinic at least once to those without an outpatient PC visit within the one-year study period. Results: 283 patients with stage III/IV colorectal (42%), gastroesophageal (23%), pancreatic (16%), hepatobiliary (12%), and other GI cancers (8%) received care within the study period (Table). Of these, 49 (17%) had at least one PC clinic visit, and 234 (83%) had no PC visits. Patients with pancreatic (35% vs 12%) and hepatobiliary cancer (20% vs 10%) were over-represented in the group receiving PC vs those without PC, while patients with colorectal cancer were under-represented (20% vs 47%). Greater percentages of patients in the group receiving PC completed advanced care planning (ACP) documents (63% vs 24%) and died during the study period (65% vs 15%). Conclusions: A minority of patients with GI malignancies at a large community cancer center are seen by an outpatient PC provider during the first year after diagnosis. These patients are more likely to have tumor types associated with worse prognosis, to complete ACPs, and to die within one year. Broader delivery of early PC will require expanded services in community cancer centers and continued development of tools for identifying patients most likely to benefit. The distribution of gastrointestinal cancer between outpatient palliative care visit and no outpatient palliative care visit. Primary cancer PC No PC Total Colorectal 10 (20% | 8%) 110 (47% | 92%) 120 (42% | 100%) Gastroesophageal 10 (20% | 16%) 54 (23% | 84%) 64 (23% | 100%) Pancreatic 17 (35% | 39%) 27 (12% | 61%) 44 (16% | 100%) Hepatobiliary 10 (20% | 30%) 23 (10% | 70%) 33 (12% | 100%) Other GI 2 (4% | 9%) 20 (9% | 91%) 22 (8% | 100%) Total 49 (100% | 17%) 234 (100% | 83%) 283 (100% | 100%) PC: Palliative care.

Provision of palliative care for people with chronic obstructive pulmonary disease: a narrative review.

Chronic obstructive pulmonary disease (COPD) is characterized by persistent and progressive airflow restriction and is the third leading cause of death and disability, globally. People with severe COPD generally experience long-term functional decline punctuated by periods of acute exacerbation. Symptom burden can be severe and debilitating, and typically includes breathlessness, cough, fatigue, pain, anxiety, depression, and overall reduced quality of life. Understanding current palliative care needs and provisions in this group is an essential step to expanding access in future. A narrative review of specialist and generalist (primary) palliative care provisions for people with COPD, with an emphasis on breathlessness symptom management. This paper aims to examine the current landscape of palliative care provision and highlight barriers and facilitators to palliative care access for people with severe COPD. People living with severe COPD, as well as the people who care for them, are routinely under-serviced in best-practice end-of-life care, despite having symptom burden that is comparable to that of people with advanced cancer. Barriers to palliative care in this group include lack of specialist palliative care resources, uncertainty surrounding prognostication, and poor recognition of need from both patients and clinicians. Routine early palliative care involvement, including integration of specialist palliative care into respiratory services and upskilling of other healthcare providers to adopt palliative care principals within usual care (primary palliative care), have been shown to improve outcomes indicative of high-quality end-of-life care in this group, including symptom control, place of death, and legal preparations. Ongoing integration of specialist palliative care and professional education for generalist and non-palliative care specialist healthcare providers in the recognition and management of unmet palliative care needs is required to increase capacity beyond traditional specialist palliative care models. Despite high level of symptom burden, many people with COPD miss out on palliative care. Expanding capacity of traditional specialist palliative care by upskilling generalist healthcare providers and integrating specialist palliative care into existing respiratory services is necessary to improve access for people with COPD.

Effects of early palliative care integration on patients with newly diagnosed multiple myeloma.

While numerous studies underscore the benefits of early palliative care (EPC) for patients with solid tumors, its effects on patients with multiple myeloma (MM) are not as widely known. This study aims to determine the effects of EPC integration on patients with newly diagnosed symptomatic MM and the feasibility of this approach. This prospective cohort study enrolled patients within eight weeks of diagnosis. Participants met with a palliative care team monthly for 12months. Functional Assessment of Cancer Therapy-General (FACT-G) plus Multiple Myeloma Subscale (FACT-MM), and Hospital Anxiety and Depression Scale (HADS) were administered upon enrollment and every three months. Proportion of completed visits and assessments determined the feasibility of EPC. Of the twenty participants enrolled from January 2020 to November 2022, median age was 65 (range 40, 77), 15 (75%) were female, 15 (75%) were white, 65% completed assessments at six months, and 60% at 12months. The following measures significantly improved at 12months versus baseline: FACT-G scoresincreased by 15.1 points (adjusted 95% CI: 2.2-28.1, adjusted p = 0.02); Functional Well-Being scores increased by 6.0 points (adjusted 95% CI: 1.1-10.9, adjusted p = 0.01); and Pain Subscale scores increased by 3.4 points (adjusted 95% CI: 0.5-6.4, adjusted p = 0.02). Depression and anxiety scores did not significantly change over time. Functional well-being, pain experience and overall QOL improved in a cohort of patients with newly diagnosed MM after 12months of EPC involvement. Although monthly visits seemed feasible, the findings suggest thatfurther researchis needed to explore the optimal timing of palliative care interventionsin the MM trajectory. ClinicalTrials.gov ID NCT04248244 (Registration Date: January 30, 2020).

Opioid initiation timing and palliative care referrals in advanced cancer: retrospective study

ObjectivesEarly opioid initiation is recommended for advanced cancer pain, however the timing of opioid commencement in relation to diagnosis has not been described, and the role of palliative care prescribers...

Palliative Care for Patients With Cancer: ASCO Guideline Update.

To provide evidence-based guidance to oncology clinicians, patients, nonprofessional caregivers, and palliative care clinicians to update the 2016 ASCO guideline on the integration of palliative care into standard oncology for all patients diagnosed with cancer. ASCO convened an Expert Panel of medical, radiation, hematology-oncology, oncology nursing, palliative care, social work, ethics, advocacy, and psycho-oncology experts. The Panel conducted a literature search, including systematic reviews, meta-analyses, and randomized controlled trials published from 2015-2023. Outcomes of interest included quality of life (QOL), patient satisfaction, physical and psychological symptoms, survival, and caregiver burden. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. The literature search identified 52 relevant studies to inform the evidence base for this guideline. Evidence-based recommendations address the integration of palliative care in oncology. Oncology clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of the disease, alongside active treatment of their cancer. For patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services complementing existing or emerging supportive care interventions. Oncology clinicians from across the interdisciplinary cancer care team may refer the caregivers (eg, family, chosen family, and friends) of patients with cancer to palliative care teams for additional support. The Expert Panel suggests early palliative care involvement, especially for patients with uncontrolled symptoms and QOL concerns. Clinicians caring for patients with solid tumors on phase I cancer trials may also refer them to specialist palliative care.Additional information is available at www.asco.org/supportive-care-guidelines.

Early Interdisciplinary Palliative Care Involvement for Patients Who Inject Drugs

Early Interdisciplinary Palliative Care Involvement for Patients Who Inject Drugs

Factors Associated With Early Palliative Care Among Patients With Heart Failure.

Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.

Long-acting opioids as a trigger for palliative care consultation in pancreatic cancer.

252 Background: Pancreatic cancer is associated with significant symptom burden, a poor prognosis, and a poor quality of life. Early involvement of palliative care alongside standard disease modifying treatment in metastatic pancreatic cancer has been associated with improved quality of life and improved symptom burden. Receipt of opioids has been shown to improve overall survival in patients with pancreatic cancer, while escalating opioid usage has been associated with higher risk of death. Given this dichotomy in prognosis, the utilization of a long-acting opioid for cancer-related pain should warrant a palliative care consultation. Methods: This is a retrospective study conducted under an IRB-approved protocol of patients who were diagnosed with pancreatic cancer between January 1, 2021 and May 30, 2023, and who had been prescribed a long-acting opioid for cancer-related pain at our institution. Data collection including patient demographics, opioid doses, hospice utilization, date of death, and aggressive interventions at end-of-life were collected via chart review. Descriptive statistics were calculated using means and medians. Statistical methods included percentage calculations of baseline characteristics. Time from initiation of long-acting opioid to death was measured. Results: Of 51 patients surveyed, 50 met eligibility criteria for our study. The median age was 66 years (Range 42-90). Stage at diagnosis included 6 resectable, 6 borderline resectable, 12 locally advanced, and 26 metastatic. Ten were able to undergo a surgical resection. 28% of patients died within 90 days of starting a long-acting opioid. 36% died within 180 days of starting a long-acting opioid. Access to palliative care services was associated with increased utilization of medical cannabis (P=0.00001) and documentation of MOLST (Medical Orders for Life Sustaining Treatment) forms (p=0.049). Access to palliative care consultation (p=0.0007) as well as access to medical cannabis (p=0.00001) was more likely at academic main site as opposed to satellite hospitals. Conclusions: The initiation of long-acting opioids in patients with advanced pancreatic cancer should be considered as a trigger for palliative care involvement as it portends a poorer prognosis. Furthermore, even at a single institution, there were disparities in access to specialty palliative care resources. Further research needs to be conducted to optimize timing of palliative care referrals in a resource limited environment.

Assessing the utilization of palliative care services in the management of patients with metastatic pancreatic adenocarcinoma.

256 Background: Pancreatic Cancer is known to be associated with poor survival outcomes and high symptom burden. Integration of early palliative care has been associated with improved end of life care, including reduced hospitalizations and emergency room visits. We conducted a retrospective study to determine the utilization rates of specialist palliative care in patients diagnosed with metastatic pancreatic cancer at an academic teaching hospital and summarize the impact on end-of-life care. Methods: A database of patients diagnosed with metastatic pancreatic cancer on index presentation from 2011 and 2022 was analyzed for utilization of specialist palliative care. Patients who transitioned cancer care to other centers and those who were lost to follow-up were excluded. Data on patient demographics, treatment course, and end-of-life care were collected, and descriptive statistics were used to summarize the data. Results: In our study, 168 patients met the inclusion criteria. The average age of diagnosis was 66 years with a diverse ethnic composition, including White (35.7%), African American (26.8%), and Hispanic (15.5%) patients. Among the cohort, 126 out of 168 (75%) patients were seen by palliative care at least once, with 79 (62.7%) of them initially seen during one of the hospitalizations, and 47 (37.3%) were seen by palliative care outpatient for the first time. The median duration between pancreatic cancer diagnosis and first encounter with palliative care was 145 days (IQR 305 days). No significant differences were found in terms of age, race, sex, ethnicity or insurance type between patients who received palliative care and those who did not. The median time from consultation to death was 57 days and 36.5% patients received palliative care only within one month of their death. Patients who received palliative care were more likely to have a DNR/DNI code status (86.7% vs. 13.3%, p &lt; 0.001) and were more likely to be enrolled in hospice care (86.3% vs. 13.7%, p &lt; 0.001). Conclusions: Early involvement of specialist palliative care in management of patients with metastatic pancreatic cancer may lead to optimization of health care services with earlier hospice referrals and comfort directed care at the end of life. Further research is warranted to explore the impact of palliative care on patient outcomes, quality of life, and the potential benefits of aligning treatment decisions with patients' end-of-life preferences.

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.

Early Palliative Care Involvement for Acute Myeloid Leukemia

Advanced practice providers are relied on to recognize patients’ need for palliative care, which has supported improved quality of life and reduced aggressive treatments near the end of life in patients with solid tumors. Hematological malignancies have similar disease trajectories and symptom burdens as solid tumors, yet palliative care is underutilized in acute myeloid leukemia, which employs aggressive therapies for management. This systematic literature review examines the 3 studies of early palliative care in patients newly diagnosed with acute myeloid leukemia. There is a strong association between early palliative care and decreased chemotherapy use and decreased intensive care unit admissions at the end of life.

Relevance of the Updated Recursive Partitioning Analysis (U-RPA) Classification in the Contemporary Care of Patients with Brain Metastases.

Patients with brain metastases (BMETS) need information about the prognosis and potential value of treatment options to make informed therapeutic decisions, but tools to predict survival in contemporary practice are scarce. We propose an Updated Recursive Partitioning Analysis (U-RPA) instrument to predict survival and benefit from brain-directed treatment (BDT) of contemporary patients. This was a retrospective analysis of patients with BMETS treated between 2017 and 2019. With survival as the primary endpoint, we calculated the U-RPA and generated estimates using Kaplan-Meier curves and hazard ratios. Of 862 eligible patients, 752 received BDT and 110 received best supportive care (BSC). Median overall survival with BDT and BSC was 9.3 and 1.3 months, respectively. Patients in RPA class 1, 2A, 2B and 3 who underwent BDT had median survival of 28.1, 14.7, 7.6 and 3.3 months, respectively. The median survival for patients in RPA 3 who received BDT (n = 147), WBRT (n = 79) and SRS (n = 54) was 3.3, 2.9 and 4.1 months, respectively. The U-RPA defines prognosis estimates, independent of tumor type and treatment modality, which can assist to make value-based care treatment decisions. The prognosis for patients in U-RPA class 2B and 3 remains poor, with consideration for early palliative care involvement in these cases.

Nationwide utilization of palliative care in patients admitted for GI malignancies.

e24114 Background: Gastrointestinal (GI) cancers account for a large proportion of cancer-related deaths and are often associated with significant impairment in quality of life, even at earlier stages. Although guidelines recommend early palliative care (PC) involvement in all patients with advanced cancer, and select patients at earlier stages, implementation of these practices has been highly variable. Methods: Using the National Inpatient Sample (NIS) database, we selected all adult patients admitted with a primary diagnosis of any GI malignancy from 2016 to 2020. We compared demographic characteristics as well as differences in in-hospital mortality, total hospital charges, and length of stay for patients who received a palliative care consultation during the admission and those who did not, with a goal of elucidating biases and informing future quality improvement efforts. Multivariate logistic regression analysis was conducted to adjust for confounders. Results: There were 1,123,075 admissions with a primary diagnosis of a GI malignancy from 2016 to 2020, which represented 0.8% of total adult admissions.10.5% of admissions included a PC consultation. Rate of PC consultation varied based on the site of primary malignancy (see table). Patients for whom PC was consulted were older (69.3 vs. 66.2 years, p &lt; 0.01), less likely to be white (62.7% vs. 67.1%, p &lt; 0.01), and more likely to have Medicare (60.4 vs. 55.5, p &lt; 0.01). These patients were 12.8 times more likely to die during admission (mortality 24.2% vs. 1.9%, p &lt; 0.01), had longer lengths of stay (8.5 vs. 6.9 days, p &lt; 0.01) and lower total charges (84,400.2 vs. 96,637.6 USD, p &lt; 0.01). Conclusions: Early PC involvement in cancer care has been associated with improvement in quality of life and decreases in costs and readmissions. Rates of PC involvement in our cohort were overall low. Different rates of consultations for different races signal possible provider bias. The significantly higher mortality in patients who received a PC consult reflects the still current practice of involving PC only at the end of life. Quality improvement efforts should focus on eliminating biases and implementing strategies to maximize early palliative care utilization among patients with locally advanced or metastatic GI malignancies. [Table: see text]

A pilot study to determine the effects of early palliative care integration on patients with newly diagnosed multiple myeloma.

e24118 Background: While multiple studies underscore the value of early palliative care (PC) involvement in patients suffering from cancer, particularly solid tumors, the effect of early integration on the care of patients with multiple myeloma is not as widely known. This study aims to obtain preliminary data on the effects of early PC involvement on patients with newly diagnosed symptomatic multiple myeloma. Methods: This is a pilot study with a prospective cohort design and based in the outpatient setting. Patients at least 18 years of age and within eight weeks of diagnosis were included. Each participant was seen by a PC specialist monthly for 12 months for ongoing symptom management and advance care planning. Quality of life was assessed using Functional Assessment of Cancer Therapy-General (FACT-G), plus the Multiple Myeloma Subscale (FACT-MM). Hospital Anxiety and Depression Scale (HADS) was used to estimate the number of participants with self-reported symptoms of depression and anxiety. Questionnaires were administered upon enrollment and every three months for 12 months. The percentage of participants who completed the study was assessed to determine the feasibility of this approach. Results: Of the twenty participants enrolled from January 2020 to November 2022, median age was 65 (range 40, 77), 15 (75%) were female, 15 (75%) were white and 11 (55%) had an Eastern Cooperative Oncology Group Performance Status score of 1. Eighty-five percent of participants completed assessment at three months, 65% at 6 months, 65% at 9 months, and 60% at 12 months. FACT-G total score was significantly higher (increased by 15.1 points) at 12 months compared to baseline (adjusted 95% CI: 2.2-28.1, adjusted p = 0.018). Functional well-being (FWB) subscale score was significantly higher (increased by 5.0 points) at 9 months compared to baseline (adjusted 95% CI: 0.5-9.5, adjusted p = 0.025), and at 12 months compared to baseline (adjusted 95% CI: 1.1-10.9, adjusted p = 0.012). Depression and anxiety scores did not significantly change over time. Conclusions: Improvement in quality of life was seen among patients with newly diagnosed symptomatic multiple myeloma after 12 months of early PC involvement. Monthly PC visits appeared to be feasible for these patients. Clinical trial information: NCT04248244 .[Table: see text]

Effect of a quality-improvement intervention on end-of-life care in cardiac intensive care unit: a single center experience

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Fondazione di Comunità Milano. Background Patients admitted to Cardiac Intensive Care Units (CICUs) have increasingly complex medical conditions; consequently, palliative care (PC) should be an integral component of their management. Although there are robust experiences emanating from other intensive care settings, there has been less discussion about the role of PC in CICUs and the delivery of end-of-life (EOL) care in this context is still very challenging. A 2019 we conducted a survey showing compelling evidence of problems with the quality of EOL care in our Tertiary Referral Hospital's CICU, with physicians often unaware of patients’ anticipated directives and very poor involvement of PC. Purpose To identify educational interventions to enhance EOL care in patients with advanced heart failure (HF) admitted to our CICU. Methods This is a before–after study showing the effect of interventions for CICU staff on competence in EOL care. The intervention was a multifaceted education program delivered by two trainers: an Associate Professor/philosopher of Law and a Clinical Psychologist. A controlled trial design was undertaken with baseline and 2 years follow-up measurement of both objective and self-perceived competence. The training intervention was a 10 hours face-to-face course involving the following techniques: a) focus group: used as a qualitative tool to identify the team's training needs; b) staff support case: clinical debriefing after challenging EOL cases; c) empowerment of communication skills. Questionnaires completed by participants were used to measure self-perceived competence. Records of all patients died with advanced HF between 2021 and 2022 (31 patients) were obtained to evaluate how therapeutic limitation was managed compared with the survey conducted between 2018 and 2019 (21 patients). The primary outcome measure was the development of objective competence in EOL management in terms of: a) report of therapeutic limitation in the prescription charts; b) adequate analgo-sedation evaluated according to pain and existential suffering control; c) early involvement of PC; d) report of patients’anticipated directives. The secondary outcome was represented by staff clinical improvements in communication, collaboration and shared decision making. Results See table. Conclusions A 2019 survey in our CICU showed that the management of advanced HF patients was aggressive. The medical and nursing staff was not sufficiently equipped with adequate practical knowledge as far as it concerns law, ethics and communication techniques. According to these observations we have planned interventions aimed at training our professionals to be knowledgeable, confident and skilled to discuss this kind of questions. After interventions, staff felt more involved and more comfortable, and reported more clarity in transitioning patients; as a consequence, we observed improvement in EOL managing.

Abstract TP108: Early Palliative Care Consultation In Patients With Disabling Stroke

Severe disability and critical illness due to stroke can be burdensome to patients, caregivers, and resource intensive, particularly in the elderly. Management of these patients is multifaceted and includes optimizing quality of life through palliative care (PC). PC in stroke patients can improve comfort while reducing overutilization of resources unlikely to prolong life or contribute meaningful quality. We investigated the impact of early PC involvement in disabled stroke patients, which we defined as NIH Stroke Score ≥ 5 and ICU admission. A screening program was implemented in 2019 at the Loyola University Medical Center for automatic PC consults in disabling stroke (ischemic or hemorrhagic) patients over age 70 or who require a ventilator. We hypothesized that early PC consultation via this protocol reduced resource consumption without compromising patient care. This pilot study gathered data prospectively for patients with a positive screen from 2020 to 2021 (“screening”, n=71), and retrospectively for those who met screening criteria in 2017 and 2018 prior to its application (“control”, n=193). Comparing the screening and control groups, there was no significant difference in age (75.9 ± 2.7 vs 72.1 ± 1.1, p&gt;0.1), NIH stroke score (16.6 ± 0.5 vs 17.5 ± 0.9, p=0.2), stroke type (61% vs 69% ischemic, p&gt;0.2), or proportion who expired (22% vs 18%, p=0.4). However, the screening group had more frequent code status change from full to DNR/DNI (42% versus 19%, p&lt;0.01) and more frequent discharges to home (20% vs 8%, p&lt;0.01) when compared to the control. These findings suggest that our samples were similar in stroke severity and screening did not affect mortality. More frequent code status changes with PC screening implies better early identification of patient centered goals of care during admission. Increased discharges to home among these patients may reduce overall long term health care utilization with clear future directives. In conclusion, our pilot study demonstrates that early palliative care involvement in patients with disabling stroke is feasible and expedites establishing goals of care without affecting the quality of care patients receive. We plan to further investigate resource utilization including ICU length of stay and cost.

Organization of pulmonary hypertension care in non-expert care settings: Lessons learned from a multi-site study.

To examine how select Veterans Health Administration (VA) sites organized care for patients with pulmonary hypertension (PH), with a focus on describing existing practices and identifying unmet needs within the sites. Semi-structured interviews across seven diverse VA sites. Qualitative multiple-site study. We interviewed 54 key informants including pulmonologists, cardiologists, primary care providers, advanced care practitioners, pharmacists, and clinical leaders to assess the structures and processes of PH care delivery. We analyzed transcripts using directed content analysis and constructed site profiles for each site, comparing profiles to existing guidelines for PH expert centers. Sites varied considerably in how they organized PH care, with wide variation in the availability of structures and processes recommended for expert centers, including availability of PH expertise and PH-specific resources, multidisciplinary approach to care, establishment of clear referral pathways, and presence of PH education. Further, participants identified three areas of unmet need not directly addressed within current guidelines, including better integration of pharmacists into multidisciplinary teams, early and routine involvement of palliative care, and improved care coordination efforts. The rising prevalence of PH and evolution of treatments for common PH subgroups underscore the need to standardize PH care delivery in non-expert care settings to improve care quality and patient outcomes. The insight gained from this study may inform the development of guidance appropriate for care settings outside of expert centers.

Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center

We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4 % out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR = 5.030, 95 % CI 1.096–23.082, p =.038) and pre-existing dementia (OR = 6.577, 95 % CI 1.726–25.073, p =.006). Average consultation timing was 8.6 (standard deviation ± 7.0) days. Patients with PC consults had longer overall (p =.0031) and intensive care unit (ICU) length of stays (LOS) (p <.0001), more days intubated (p <.0001) and higher costs (p =.0006), although those with earlier-than-average PC consultation had shorter overall (p =.0062) and ICU (p =.011) LOS as well as fewer ventilator days (p =.030) and lower costs (p =.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.

EOLP-02. THE EFFECT OF CLINICAL TRIAL ENROLLMENT ON SPECIALTY PALLIATIVE CARE RECEIPT IN PEDIATRIC AND YOUNG ADULT PATIENTS WITH HIGH GRADE GLIOMAS

Abstract BACKGROUND Palliative care has been shown to provide numerous benefits to children with cancer. Pediatric patients with high grade glioma (HGG) are particularly well suited for early involvement of palliative care given their high symptom burden and relatively poor prognosis. However, a recent study revealed that pediatric patients with primary central nervous system malignancies missed multiple opportunities for appropriate palliative care involvement. We hypothesize that clinical trial enrollment may adversely impact palliative care involvement for children and young adults with HGG. METHODS We identified a cohort of 43 deceased patients with HGG treated at our institution. IRB exemption was obtained. For each patient, the electronic medical record was reviewed to collect demographic, diagnostic, clinical trial, treatment, and palliative care information. Statistical analysis was performed, employing Fisher exact and t tests. RESULTS Overall, 72% (31/43) of patients had at least one visit with a specialty palliative care provider. 56% (24/43) of patients enrolled in a clinical trial with HGG-directed therapy, with 71% (17/24) of patients who enrolled in a clinical trial receiving specialty palliative care compared to 74% (14/19) of patients who were not on a trial (p = 1.000). Among patients who received palliative care, there was no statistically significant difference in the timing of palliative care involvement, measured from the date of first palliative care contact to date of death, for patients who enrolled in a clinical trial (mean = 177 days) compared to those who did not (mean = 113 days, p = 0.180). CONCLUSIONS As our understanding of the genomic landscape of pediatric brain tumors increases, it can be expected that patients electing to enroll in targeted therapy clinical trials will also increase. As such, it is reassuring that our data suggest trial participation does not adversely impact the receipt of palliative care in children with HGG.

EFFECT ON LENGTH OF STAY AND MORTALITY AFTER INITIATION OF EARLY PALLIATIVE CARE CONSULTATION IN A COMMUNITY HOSPITAL ICU: A QUALITY IMPROVEMENT PROJECT

EFFECT ON LENGTH OF STAY AND MORTALITY AFTER INITIATION OF EARLY PALLIATIVE CARE CONSULTATION IN A COMMUNITY HOSPITAL ICU: A QUALITY IMPROVEMENT PROJECT