Early Palliative Care Consultation Research Articles

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.

In high-risk ICU patients, early palliative care consultation increased transition to DNR/DNI status.

Source Citation Ma J, Chi S, Buettner B, et al. Early palliative care consultation in the medical ICU: a cluster randomized crossover trial. Crit Care Med. 2019;47:1707-15. 31609772

Timing and location of palliative care consultation in metastatic pancreatic cancer: A retrospective, single-center observational study.

770 Background: Patients (pts) receiving treatment for metastatic pancreatic cancer (MPC) experience significant symptoms, treatment related side effects and psychosocial burdens. The ASCO guidelines recommend early palliative care consultation (PCC) to improve quality of life and survival. However, limited real-world data is available regarding the timing of PCC, hospice enrollment and location of death (LOD) in pts with MPC. Methods: We conducted a retrospective observational analysis of pts treated with chemotherapy for MPC at the Yale Smilow Cancer Hospital and affiliated community care centers (CCC) from January 2011 to April 2019. Patient demographics, treatment dates, initial PCC, enrollment of hospice at the time of death and LOD were manually abstracted from the electronic medical record. Univariate and multivariable logistic regression analyses were conducted to predict for PCC and death outside the hospital. Results: Of 363 pts identified with MPC who received chemotherapy, 38% (138) had a PCC. 67% (93) of patients’ initial PCC was in the hospital versus 33% (45) in the outpatient setting. The median time from the start of first-line chemotherapy to the first PCC was 5.2 months (interquartile range [IQR] 1.2 – 12.9). The median time from the first PCC to death was 1.5 months (IQR 0.5 – 4.42). At the time of our analysis, 300 pts had died and of those 76% (229) were enrolled on hospice at the time of death while 24% (71) were not. With respect to LOD, 47% (139) of pts died at home with hospice, 31% (94) at an inpatient hospice facility and 22% (67) died in the hospital. Female gender was associated with an increased likelihood of a PCC (HR 1.78, 95% CI 1.07-2.94, P = 0.026). Pts treated at a CCC were less likely to have a PCC (HR 0.21, 95% CI 0.12-0.36, P < 0.001). A PCC was not associated with a higher likelihood of death outside the hospital (HR 1.31, 95% CI 0.75-2.29, P = 0.346). Conclusions: Although most pts with MPC enroll in hospice, PCC is generally underutilized. In fact, many pts receive PCC near the end of life and in the hospital. Further studies are warranted to determine how best to incorporate early PCC to maximize supportive care for pts with MPC.

Early Palliative Care Consultation for Critically Ill Patients

Most clinicians who work in intensive care units (ICUs) can tell stories about benefits of collaborating with palliative care teams. Despite this

Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial.

To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients. Single-center cluster randomized crossover trial. Two medical ICUs at Barnes Jewish Hospital. Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality. The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission. Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) (p > 0.05). Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.

EARLY VS USUAL PALLIATIVE CARE CONSULTATION IN THE ICU: AUGMENTING THE CRITICAL CARE PHYSICIAN TO DECREASE IN-HOSPITAL MORTALITY

SESSION TITLE: Palliative Care and End-of-Life SESSION TYPE: Original Investigations PRESENTED ON: 10/20/2019 2:15 PM - 3:15 PM PURPOSE: Around 1/5 of all deaths in the USA occur in or around an Intensive Care Unit (ICU) admission. This admission may result in changing goals of care from cure to comfort, but sometimes too late. Palliative care medicine’s (PCM) role as defined by Institute of Medicine is to “prevent, relieve, reduce, or soothe the symptoms of disease or disorder without effecting a cure” so they are a specialty that would assist with this transition. Researchers have shown a decreased length of stay and costs when PCM was involved early in the ICU stay. Other studies have tried to show an improvement in patient and family member/caregiver satisfaction scores, but have failed due to low sample sizes. There have been no studies to compare if an early palliative care consult (within 24 hours) improves mortality or decreases hospital deaths when compared to usual palliative care consultation (whenever the treating team deems is appropriate). METHODS: We performed a randomized controlled trial in a medical ICU (MICU) from 10/1/2018 to 11/30/2018. Adult patients were included if they met just one of these criteria 1) age>80 years, 2> APACHE II score >14, 3) SOFA score >9, 4) Pre-existing functional dependency, 5) late stage dementia, 6) metastatic cancer, 7) consideration to place a permanent feeding tube or tracheostomy, 8) recurrent ICU admissions, 9) post-cardiac arrest, or 10) end stage organ failure. Patients were excluded if they have already seen palliative care medicine. Once included in the study, the patients were randomized to either group by a random number generator. The patients randomized to the treatment group had a palliative care consultation within 24 hours of MICU admission. RESULTS: A total of 29 patients were randomized (14 in the early and 15 in the usual palliative care group). Baseline patient characteristics were not different between groups. The early palliative care group had a lower hospital mortality when compared to the usual care group (0 vs 6; p=0.04). More patients were discharged to hospice in the early group (4 vs 0; p=0.01). There also were more healthcare surrogates chosen in the hospital in the early group (7 vs 0; p<0.01). There was no difference in ICU or hospital length of stay or code status changes. CONCLUSIONS: This is the only study that has been performed to evaluate early palliative care consultation as defined as within 24 hours of ICU admission and its impact in patient care. We have shown in this study that patients who receive an early palliative care consultation have a lower in-hospital mortality resulting in more discharges to hospice. Also, this study shows that more healthcare surrogates are chosen in the hospital when palliative care medicine is involved earlier. CLINICAL IMPLICATIONS: Palliative care is able to augment the Critical Care physician's ability to take care of end-of-life patients when involved early resulting in a lower ICU and hospital mortality. DISCLOSURES: No relevant relationships by Rebecca Burnside, source=Web Response No relevant relationships by Scott Helgeson, source=Web Response No relevant relationships by John Moss, source=Web Response No relevant relationships by Maisha Robinson, source=Web Response

Integration of palliative care into the inpatient oncology service.

46 Background: Research has demonstrated that early palliative care involvement for patients with advanced cancer has multiple benefits, including improved symptom control/quality of life and reduced readmission rates. Based on this data, the American Society of Clinical Oncology (ASCO) has developed guidelines for early palliative care consultation. At the University of Vermont Medical Center, historically 40% of such patients were evaluated by palliative care during hospital admission. The purpose of this study was to better integrate palliative care into the oncology inpatient setting through the use of a standardized admission template. Methods: A specific oncology H&amp;P template, with inclusion of a drop down menu of ASCO based criteria for palliative care consultation, was created. Providers were educated on template use, and data then were collected for oncology admissions from 2/1-8/31/2018 regarding template usage, if criteria was met for palliative care consultation, and whether consultation occurred. Additionally, 30 day post discharge ED visits and readmissions were recorded, extending data collection for this purpose to 9/30/2018. Results: There were 372 medical oncology admissions during the studied time period, with 284 individual patients. The template was used for 95 (26%) admissions. 267 of those patients admitted qualified for palliative care consultation and, of those in which the template was used, 72% had palliative care consulted versus 50% without the template (p= 0.0013). There was no statistically significant difference in readmission rates between those with palliative care consultation and without. Conclusions: Early palliative care consultation for patients with advanced malignancy has been shown to have multiple benefits on an individual and system-wide basis. It was shown in this study that, though the created template was used for a minority of admissions, with template use a significantly greater proportion of appropriate patients had palliative care consulted. This suggests that, with more widespread practice, this strategy could further promote inpatient palliative care involvement for appropriate oncology patients.

Patterns of Palliative Care Consultation Among Patients with Brain Metastasis: An Opportunity for Radiation Oncologists to Facilitate Earlier Referral

Background Early palliative care (PC) physician involvement alongside standard oncologic care has been recommended by the American Society of Clinical Oncology (ASCO) guidelines for all advanced cancer patients, although adherence to these guidelines is variable. Radiation oncologists (ROs) could help facilitate early PC referral for patients treated with palliative radiation, particularly those with brain metastasis (BRM), and the aim of this study was to evaluate the circumstances of PC referral at our institution to better understand the multidisciplinary approaches to facilitate it. Methods Patients diagnosed with BRM from non-small cell lung cancer (NSCLC) from 2012 to 2018 whose primary RO and MO were at our institution were reviewed. Overall survival and time to PC consultation from the first oncologic visit following BRM diagnosis was determined using the KaplanMeier method. Mann-Whitney U and Chi-Squared assessed for predictive factors for shorter time to PC consultation. For these factors, the overall survival, rate of PC consultation, and PC setting was used to determine utilization of early PC. Results Among 103 eligible patients, only 48% underwent a PC consultation in their lifetime, with the initial evaluation being as an outpatient for 37%, and within 1 month of death for 35%. Median survival from BRM diagnosis was 9.0 months. The median time from oncologic appointment to PC referral was 2.8 months, and from initial PC consultation to death was 1.6 months. Only more recent BRM diagnosis (2016-2018 vs. 2012-2015) was associated with shorter time to PC consultation (1.0 vs. 5.6 months, P=0.013), increased PC consult rate (60% vs. 42%, P=0.105), and increased outpatient PC consultation (56% vs. 26%, P=0.037). Conclusions The majority of patients did not undergo early PC consultation, though utilization has improved over time. As ROs are commonly involved in BRM management, they may be in a position to proactively support early PC consultations in this patient population.

Implications of Palliative Care Consultation Timing among a Cohort of Hospice Decedents.

Background: Earlier palliative care consultation is associated with less intensive medical care and improved quality outcomes for patients with cancer. However, there are limited data about how the timing of palliative care affects utilization among noncancer patients exposed to palliative care consultation. Objective: Comparison of health care utilization for hospice decedents who received early versus late palliative care. Design: A retrospective cohort study utilizing hospital and hospice administrative databases. Setting/Subjects: Patients with cancer and noncancer diagnoses who received specialty palliative care consultation before dying at a local hospice. Measurements: Comparing early (>90 days before death) versus late (<90 days before death) palliative care, outcome measures included intensive care unit (ICU) utilization and hospice length of stay (LOS). Results: Of 233 hospice decedents in 2014 who had palliative care referrals, 36 (15.4%) had early and 197 (84.5%) had late referrals. Nearly half of the patients had a noncancer hospice diagnosis. Only 6% of the early group used the ICU in the last month of life, whereas 56% of the late group did. Patients receiving early palliative care had a longer median hospice LOS than those with late palliative care (138 days vs. 8 days). Conclusions: Early palliative care appears to reduce intensive medical care and increase hospice LOS for patients with a variety of end-stage diseases.

Abstract TP348: Early Palliative Care Consultation in Acute Stroke

Introduction: Despite great strides in management, stroke remains a significant cause of disability and death. Families are often abruptly confronted with critical decisions about end-of-life care; providers must balance these concerns with urgent medical or surgical treatment and an uncertain prognosis. This trial examined early Palliative Care (PC) consultation as a means to assist acutely ill patients and their families. Methods: This interdisciplinary, prospective, randomized trial used alternating days to dichotomize patients into a control group who received routine care, including PC consultation if appropriate, and an intervention group, who had PC consultation on the day after admission. Inclusion criteria were a diagnosis of acute ischemic or hemorrhagic stroke, admission to the neurological intensive care unit, and any one of: NIHSS &gt; 14, baseline severe cognitive dysfunction, premorbid modified Rankin score &gt; 3, metastatic cancer, intubation at admission, prior stroke with disability, readmission within 30 days, or admission from a nursing facility. PC consultation identified surrogate decision makers, addressed advance care directives and code status, and co-facilitated multidisciplinary meetings. Outcome measures were identification of a surrogate, documentation of code status, discharge destination and length of stay. Results: We enrolled 50 patients in the PC intervention group. Of the 64 patients in the control group, 18 had PC consultations as routine care; 46 (72%) did not have PC consults. There were no differences between the groups in surrogate identification, documentation of code status or discharge destination. However, compared with the 46 control patients without PC consultation, the intervention group had a significantly higher rate of surrogate identification (98% vs. 87%), χ2 (1) = 4.32, p = 0.037, and code status documentation (94% vs. 78%), χ2 (1) = 5.07, p = 0.024. Length of stay data is pending; not all patients had been discharged at the time of submission. Conclusion: Palliative Care consultation, particularly when pursued early in a patient’s hospitalization for acute stroke allows for clear documentation of a surrogate and delineation of code status, both critical to a patient’s trajectory after acute stroke.

The Discrepancy Between Palliative and Oncology Providers in Palliative Referrals (QI704)

1.Justify the need for palliative care consultation to outpatient oncologists by meeting with them on a regular basis in order to increase the rate of referrals.2.Identify other patient-centered outcomes as a result of proactive palliative care consultation, including rate of completion of advance directives, rate of state-authorized portable orders (SAPO) completion, and rates of in-hospital and community deaths. According to NCCN and ASCO guidelines, there is evidence that early palliative care consultation in patients with advanced cancer led to significant improvement in quality of life, mood and longer survival as compared to patients receiving standard care. To improve the rate of palliative care consultation by 20% in patients with advanced cancer over a 15 month period at Buffalo Veterans Affairs Medical Center (VAMC). Buffalo VAMC is an academic center affiliated with the University at Buffalo. We provide both outpatient palliative and oncology services. In 2017, we decided to seek proactive palliative care consultations (PPCC) with advanced cancer patients; defined as stage 4 lung cancer, any pancreatic cancer, or any cancer with more than 1 emergency, hospital or ICU admissions. Based on our root analysis our intervention was a meeting between palliative and oncology services once a week since 01/01/2017 to 3/30/2018 at the VA and reviewing the oncology cases on weekly basis with average 80-100 patients per week. From 163 patients requested to be seen by palliative team, oncologists approved 63 proactive palliative consults with denial rate of 60%. PPCC resulted in an increase of referrals by 33% over a 15 month period. Of those patients seen by outpatient palliative care, 92% died in a community setting (hospice or home) while those identified but denied PPCC died in the community setting only 50% of the time. Interestingly, patients whose PPCC were denied but were later seen by the palliative care team during a hospital admission died in the community 91% of the time. In addition, advanced directives and SAPO increased by 30% and 65% respectively. Seeking proactive palliative care consultation in patients with advanced cancer led to an increased outpatient referral rate with a simultaneous decrease in in-hospital mortality.

Early Palliative Care Consultation in the Medical Intensive Care Unit—A Clustered Randomized Crossover Trial (TH371B)

Early Palliative Care Consultation in the Medical Intensive Care Unit—A Clustered Randomized Crossover Trial (TH371B)

Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions

IntroductionMany injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources. MethodsTrauma Quality Improvement Program (2013–2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student’s t tests or Wilcoxon rank sum tests; significance for p < 0.05. ResultsWe identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC. ConclusionWLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.

Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study.

Little is known about palliative care consultation (PCC) for patients with cardiogenic shock requiring short-term mechanical circulatory support (STMCS). To describe the utilization of PCC in this population. Retrospective cohort study in a university medical center intensive care unit (ICU). In total, 195 patients aged >18 years with cardiogenic shock requiring STMCS were included. The cohort was divided into three categories: no PCC, early PCC (within seven days of STMCS), and late PCC (eight or more days after STMCS). Follow-up occurred during the index hospitalization. Mean age was 59.3 ± 13.9 years; 67.9% were men. Mean follow-up period was 33.8 ± 37.7 days. Overall inpatient mortality was 52.3%. Ninety-four patients (48.2%) received PCC; 49 (25.1%) and 45 (23.1%) received early and late PCCs, respectively. STMCS duration, ICU stay after STMCS, and hospital stay after STMCS were significantly shorter in the no PCC group than the early PCC group (4 vs. 12 days, p < 0.001; 11 vs. 19 days, p = 0.004; and 16 vs. 19 days, p = 0.031; respectively). ICU stay after STMCS and hospital stay after STMCS were significantly shorter in the early PCC group than the late PCC group (19 vs. 38 days, p < 0.001; 19 vs. 49 days, p < 0.001; respectively). However, time from initial PCC to discharge was not significantly different between early and late PCC groups (18 vs. 31 days, p = 0.13). PCC was utilized in almost half of patients with cardiogenic shock requiring STMCS. PCC tends to occur toward the end of life regardless of the duration of STMCS. The optimal PCC timing remained unclear.

Impact of a mature palliative service for patients with lung cancer admitted to the ICU.

102 Background: In 2012 ASCO made the clinical recommendation for patients with stage IV solid organ cancer to receive palliative care consultation (PCC) at the time of detection. This was intended to increase utilization and effectiveness of palliative care. In this study, we estimate the proportion and impact of late "brink of death" PCC for patients with stage III-IV lung cancer admitted to the ICU of a hospital with a Joint Commission approved palliative care program. Methods: Retrospective review of patients with advanced lung cancer (stage III-IV) admitted to ICU in 2015-17. IRB approval was obtained. There were no exclusion criteria within this population. Areas assessed were age, stage, reason for admission, interventions, disposition, length of stay, days in the intensive care unit, palliative care consultation, code status, and documented end of life discussion. Results: A total of 13 patient met inclusion criteria. They were 38% male 62% female with a mean age of 67 years (SD: 14.9). All had prior diagnosis of advanced lung cancer and 92% were stage IV. The most common indication for admission was sepsis (38%). Less than half (46%) had a PCC, and fewer (31%) had a documented end of life care discussion. Even in the minority of patients with PCC, 33% received the PCC on day of death. Full code status was maintained in 77%. 53% expired during admission with only 57% of those that died having palliative care discussion. Conclusions: Even in a mature TJC certified PCC program, less than half of these terminally ill patients received a PCC. There is a chasm between ASCO's goal of early PCC and the reality of palliative care utilization in ICU admitted patients with advanced lung cancer. A possible solution is to initiate triggered palliative consultation for this high mortality population upon admission, with possible expansion to other terminally ill groups. In a world of electronic medical records, it should be possible to arrange a system to flag these patients for direct review by the palliative team to determine appropriateness and then notify the primary team in order to coordinate care.[Table: see text]

Association of emergency department admission and early inpatient palliative care consultation with hospital mortality in a comprehensive cancer center

Consultation to palliative care (PC) services in hospitalized patients is frequently late after admission to a hospital. The purpose of this study is to examine the association of in-hospital mortality and timing of palliative care consultation in cancer patients admitted through the emergency department (ED) of MD Anderson Cancer Center. Institutional databases were queried for unique medical admissions over a period of 1year. Primary cancer type, ED versus direct admission, length of stay (LOS), presenting symptoms, and in-hospital mortality were reviewed; patient data were analyzed, and risk factors for in-hospital mortality were identified. The association of early palliative care consultation (within 3days of admission) with these outcomes was studied. Descriptive statistics and multivariate logistic regression model were used. Equal numbers of patients were admitted directly versus through the ED (7598 and 7538 respectively). However, of all patients who died in the hospital, 990 (88%) were admitted through the ED, compared with 137 admitted directly (P < 0.001). Patients who died in the hospital had longer median LOS compared with patients who were discharged alive (11 vs. 4days, respectively, P < 0.001). Early palliative care consultation was associated with decreased mortality, compared with late consultation (P < 0.001). Chief complaints of respiratory problems, neurologic issues, or fatigue/weakness were significantly associated with in-hospital mortality. We found an association between ED admission and hospital mortality. Decedent cancer patients had a prolonged LOS, and early palliative care consultation for terminally ill symptomatic patients may prevent in-hospital mortality and improve quality of cancer care.

Inpatient Palliative Care Consultations From a Canadian Clinical Teaching Unit: Who is Referred and When?

Inpatient palliative care consultation has been demonstrated to improve quality of life as well as decrease hospital readmissions, intensive care unit transfers, and hospital costs for people with a life limiting illness. The clinical teaching units (CTUs) at London Health Sciences Centre (LHSC) routinely admit patients with noncurable cancer as well as end-stage heart, lung, liver, or kidney disease. However, the use of inpatient palliative care consultations for CTU patients remains unexamined. We conducted a descriptive study of all patients referred from LHSC CTU from both University and Victoria hospital to inpatient palliative care over a 1-year period from August 2013 to July 2014. The purpose of this study was to characterize the population and identify possible areas for quality improvement. In a 1-year period, 638 patients were referred from CTU to the inpatient palliative care consultation service. Of referrals, 55% died during their admission. Based on data collected, we conclude that many patients are referred early in their admission to CTU and patients are referred for a variety of noncancer diseases, suggesting knowledge and appreciation of the benefit of early palliative care consultation for malignant and nonmalignant disease. However, when further analyzed, there is indication that patients with noncancer diagnoses are referred statistically significantly later than those with a cancer diagnosis. The CTUs are sites of core medical training, and therefore, it is imperative that we model early integration of palliative care in order to continue to improve care of patients at end of life.

The impact of palliative care consultation on overall survival and aggressive care at the end-of-life in unresectable pancreatic cancer.

e18729Background: Early Palliative Care consultation has been associated with improved overall survival (OS) and lower aggressiveness of end-of-life care (AEOLC) in a number of malignancies. For pa...

Early palliative care consultation reduces hospital costs

Early palliative care consultation reduces hospital costs

Universal Precautions for Opioid Prescribing in Ambulatory Palliative Care (FR441D)

•Discuss implementation of universal precautions in opioid prescribing within a population of people with serious illness.•Discuss the outcomes of the first year implementation of universal precautions in opioid prescribing in the palliative care clinic. Opioid overdose deaths have dramatically increased throughout the United States. Palliative care has been excluded from many practice guideline changes in opioid risk assessment and prescribing. Yet, emerging evidence suggests that the risks for abuse, misuse and diversion may be the same in this population. With the trend toward earlier palliative care consultation and the development of ambulatory palliative care clinics, adapting universal precautions for opioid prescribing may improve both the safety and effectiveness of opioid management in the seriously ill population. To assess the feasibility of implementing universal precautions for opioid prescribing for seriously ill patients in the palliative care clinic. Internal interdisciplinary guidelines and processes for opioid risk assessment and monitoring were developed and implemented in October 2016. Charts were reviewed from the first weeks of October 2016, January 2017, and April 2017 for key items of the opioid prescribing guidelines. Information was de-identified, aggregated, and evaluated using descriptive statistics. Sixty-eight patients were seen in the palliative care clinic and 32 (47%) were prescribed opioids by the palliative care clinician. Of these 32 patients, 90% had an opioid management plan, 78% had a urine drug screen completed at the current or prior visit, and 75% had an opioid treatment agreement on file. The mean morphine equivalent daily dose was 316 mg. Opioid risk stratification was assessed and documented in 25 patients (78%), and of these eight (33%) were high risk. All high risk patients were referred to social work. Implementation of universal opioid precautions is feasible and may identify at-risk patients and enable clinicians to provide safer opioid management without an increase in clinic staff. Further work is necessary to improve clinician utilization of the guidelines. In-depth analysis may provide valuable information to inform risk assessment and prescribing practices.