Early Palliative Care Research Articles

Patient and Provider Attitudes and Preferences Regarding Early Palliative Care Delivery for Patients with Advanced Gastrointestinal Cancers: A Prospective Survey.

Early integrated palliative care (EIPC) for patients with advanced cancers requires the involvement of family doctors (FDs) and oncologists. We compared attitudes between patients and their providers regarding the delivery of EIPC. Patients with newly diagnosed incurable gastrointestinal (GI) cancer at a tertiary cancer centre in Ontario, Canada, were surveyed using a study-specific instrument regarding the importance of and preferences for accessing support across eight domains of palliative care. Physicians within the circle of care completed a parallel survey for each patient. The concordance between patient and physician responses was analyzed. A total of 66 patients were surveyed (median age 69, 35% female). All had an oncologist, 12% had a specialist palliative care provider (SPC), and 97% had an FD, but only 41% listed the FD as part of the care team. In total, 95 providers responded (oncologist = 68, FD = 21, SPC = 6; response rate 92%; 1-3 physician responses per patient). Disease management and physical concerns were most important to patients. Patients preferred to access care in these domains from oncologists or SPCs. For all other domains, most patients attributed primary responsibility to self or family rather than any healthcare provider. Thus, concordance was poor between patient and physician responses. Across most domains of palliative care, we found low agreement between cancer patients and their physicians regarding responsibilities for care, with FDs appearing to have limited involvement at this stage.

Comparative effectiveness trial of early palliative care delivered via telehealth versus in person among patients with advanced lung cancer.

LBA3 Background: National guidelines recommend the early integration of palliative and oncology care for patients with advanced cancer, given robust evidence showing that this care model improves quality of life (QOL) and other important outcomes. However, most patients do not receive early palliative care (EPC) in the outpatient setting due to limited access and resources. To overcome these barriers, we conducted a large-scale comparative effectiveness trial of EPC delivered via secure video versus in person among patients with advanced non-small cell lung cancer (NSCLC) and their caregivers. Methods: Between 6/14/2018 and 5/4/2023, we enrolled 1250 patients with advanced NSCLC, diagnosed in the past 12 weeks, into a randomized trial of telehealth versus in-person EPC across 22 cancer centers in the US. Patients were randomly assigned to meet with a palliative care clinician every four weeks from enrollment through the course of disease either via video or in the outpatient clinic. Participants completed self-report measures at baseline and weeks 12 and 24. The primary aim was to evaluate the equivalence of the effect of telehealth versus in-person EPC on QOL at week 24, using regression modeling with an equivalence margin of ±4 points on the Functional Assessment of Cancer Therapy-Lung (FACT-L, range = 0-136). We also compared rates of caregiver participation in EPC visits and patient-reported depression and anxiety symptoms (Patient Health Questionnaire-9; Hospital Anxiety and Depression Scale), coping (Brief COPE), and perceptions of prognosis (Perceptions of Treatment and Prognosis Questionnaire) between groups. Study recruitment ceased for two months at the onset of the COVID-19 pandemic. Results: Participants (mean age = 65.5 years; 54.0% female; 82.1% White) had a mean of 4.75 and 4.92 palliative care encounters by week 24 in the telehealth and in-person groups, respectively. Due to the pandemic, the in-person group had 3.9% of visits occur via video. QOL scores at week 24 for patients assigned to the telehealth group were equivalent to those receiving in-person EPC (adjusted means: 99.67 versus 97.67, p < 0.043 for equivalence). The rate of caregiver participation in EPC visits was lower in the telehealth versus in-person group (36.6% versus 49.7%, p < 0.0001). Study groups did not differ in depression and anxiety symptoms, use of coping skills, or perceptions of the goal of treatment and curability of their cancer. Conclusions: The delivery of EPC via video versus in-person visits demonstrated equivalent effects on QOL in patients with advanced NSCLC. The two modalities also did not differ across a range of patient-reported outcomes, though caregivers attended more in-person versus video visits. The findings underscore the considerable potential for improving access to and broader dissemination of this evidence-based care model through telehealth delivery. Clinical trial information: NCT03375489 .

Stepped Palliative Care for Patients With Advanced Lung Cancer

Despite the evidence for early palliative care improving outcomes, it has not been widely implemented in part due to palliative care workforce limitations. To evaluate a stepped-care model to deliver less resource-intensive and more patient-centered palliative care for patients with advanced cancer. Randomized, nonblinded, noninferiority trial of stepped vs early palliative care conducted between February 12, 2018, and December 15, 2022, at 3 academic medical centers in Boston, Massachusetts, Philadelphia, Pennsylvania, and Durham, North Carolina, among 507 patients who had been diagnosed with advanced lung cancer within the past 12 weeks. Step 1 of the intervention was an initial palliative care visit within 4 weeks of enrollment and subsequent visits only at the time of a change in cancer treatment or after a hospitalization. During step 1, patients completed a measure of quality of life (QOL; Functional Assessment of Cancer Therapy-Lung [FACT-L]; range, 0-136, with higher scores indicating better QOL) every 6 weeks, and those with a 10-point or greater decrease from baseline were stepped up to meet with the palliative care clinician every 4 weeks (intervention step 2). Patients assigned to early palliative care had palliative care visits every 4 weeks after enrollment. Noninferiority (margin = -4.5) of the effect of stepped vs early palliative care on patient-reported QOL on the FACT-L at week 24. The sample (n = 507) mostly included patients with advanced non-small cell lung cancer (78.3%; mean age, 66.5 years; 51.4% female; 84.6% White). The mean number of palliative care visits by week 24 was 2.4 for stepped palliative care and 4.7 for early palliative care (adjusted mean difference, -2.3; P < .001). FACT-L scores at week 24 for the stepped palliative care group were noninferior to scores among those receiving early palliative care (adjusted FACT-L mean score, 100.6 vs 97.8, respectively; difference, 2.9; lower 1-sided 95% confidence limit, -0.1; P < .001 for noninferiority). Although the rate of end-of-life care communication was also noninferior between groups, noninferiority was not demonstrated for days in hospice (adjusted mean, 19.5 with stepped palliative care vs 34.6 with early palliative care; P = .91). A stepped-care model, with palliative care visits occurring only at key points in patients' cancer trajectories and using a decrement in QOL to trigger more intensive palliative care exposure, resulted in fewer palliative care visits without diminishing the benefits for patients' QOL. While stepped palliative care was associated with fewer days in hospice, it is a more scalable way to deliver early palliative care to enhance patient-reported outcomes. ClinicalTrials.gov Identifier: NCT03337399.

Early palliative care among patients diagnosed with advanced cancers in the US (2010-2019): Trends and contribution of provider variation.

11017 Background: Early integration of palliative care (PC) is recommended for advanced cancers, but evidence of its use and the role of provider practice patterns and organizational characteristics in uptake is limited. This study examined recent trends of early PC among Medicare beneficiaries newly diagnosed with advanced cancers, and provider- and organization-variation in the receipt of early PC. Methods: We identified patients aged ≥65.5 years newly diagnosed with advanced stage breast, colorectal, non-small cell lung (NSCL), small cell lung (SCL), pancreas, and prostate cancers in 2010-2019 with ≥6 months survival and continuous fee-for-service coverage from the linked SEER-Medicare data. Early PC was identified by claims with corresponding diagnosis codes or hospice and palliative medicine provider specialty codes within 90 days post-diagnosis or up to first hospice admission date (whichever came earlier). Treating physicians and corresponding organizations (i.e., Tax Identification Number) were assigned based on the plurality of visits within 180 days after diagnosis. We described the percent of patients receiving early PC each year. Generalized linear models with physician- and organization-fixed effects evaluated variation in early PC receipt between and within physicians/organizations. Results: Among 103,045 patients treated by 25,736 unique providers and 11,163 organizations, the percent receiving early PC increased from 0.98% in 2010 to 10.64% in 2019. Although statistically significant increases were observed across cancer types, receipt in patients with prostate cancer was relatively lower compared to pancreas, SCL, NSCL, and breast cancers (Table). After adjusting for patients’ characteristics, variation in early PC use between treating providers and organizations explained 47.9% and 31.2% of the total variation, respectively. Conclusions: Despite considerable growth in early PC receipt, utilization remained low in 2019. The large variation between providers and organizations suggests important modifiable provider behaviors and organizational characteristics in early PC use, which warrant future research. [Table: see text]

Why and How to Integrate Early Palliative Care Into Cutting-Edge Personalized Cancer Care.

Early palliative care, palliative care integrated with oncology care early in the course of illness, has myriad benefits for patients and their caregivers, including improved quality of life, reduced physical and psychological symptom burden, enhanced prognostic awareness, and reduced health care utilization at the end of life. Although ASCO and others recommend early palliative care for all patients with advanced cancer, widespread implementation of early palliative care has not been realized because of barriers such as insufficient reimbursement and a palliative care workforce shortage. Investigators have recently tested several implementation strategies to overcome these barriers, including triggers for palliative care consultations, telehealth delivery, navigator-delivered interventions, and primary palliative care interventions. More research is needed to identify mechanisms to distribute palliative care optimally and equitably. Simultaneously, the transformation of the oncology treatment landscape has led to shifts in the supportive care needs of patients and caregivers, who may experience longer, uncertain trajectories of cancer. Now, palliative care also plays a clear role in the care of patients with hematologic malignancies and may be beneficial for patients undergoing phase I clinical trials and their caregivers. Further research and clinical guidance regarding how to balance the risks and benefits of opioid therapy and safely manage cancer-related pain across this wide range of settings are urgently needed. The strengths of early palliative care in supporting patients' and caregivers' coping and centering decisions on their goals and values remain valuable in the care of patients receiving cutting-edge personalized cancer care.

Impact of COVID-19 on referrals to outpatient palliative care for patients with advanced cancer in a safety-net health system.

e24071 Background: Medically underserved adults with cancer experience challenges with access to care and tend to present at later disease stage. Amidst the complex needs of safety-net patients, the value of early palliative care (PC) services can go unrecognized. Few studies have examined PC referral patterns in the outpatient setting among advanced cancer patients within a safety-net system, and none has studied how or whether referrals have evolved since the most acute stages of the COVID-19 pandemic. This study examined PC referrals for cancer patients seen as outpatients in the urban safety-net primary provider of cancer care for uninsured individuals in Dallas, TX, and assessed changes from before to after the acute pandemic phase. Methods: We used tumor registry records linked to outpatient PC referral data from the safety-net health system’s electronic health record from January 1, 2018 to July 31, 2023. The primary outcome was a binary indicator for receipt of PC referral among patients diagnosed with advanced-stage solid tumor cancer. Using a multivariate logistic regression model, we evaluated whether our independent variable – a binary indicator for pre-pandemic (January 1, 2018 to February 28, 2020) and post-pandemic (March 1, 2020 to July 31, 2023) time periods – was associated with PC referrals. We included age, sex, race/ethnicity, cancer type, preferred language, and insurance as covariates. Results: Among 1,590 eligible patients (mean age 58.1, range: 21-94), 44% were female and 75% were non-White. Diagnoses included lung (20%), gastrointestinal (17%), colorectal (14%), breast (9%), prostate (9%), head/neck (9%), pancreatic (8%), gynecologic (6%), and other (8%) cancers. Across both time periods, a total of 785 (49%) of patients received a PC referral. Whereas 53% of the 754 patients in the pre-pandemic cohort received a PC referral, 46% of the 836 in the post-pandemic cohort received a referral. In the adjusted regression model, pre-pandemic patients were 1.26 times more likely to have a PC referral than post-pandemic patients (95% CI, 1.02-1.56). Referrals varied by cancer type across both time periods – compared to breast cancer patients, gynecologic cancer patients had lower odds of PC referral (aOR, 0.19; 95% CI, 0.10-0.36) and pancreatic cancer patients had higher odds of PC referral (aOR, 2.93; 95% CI, 1.71-5.00). Conclusions: Our analysis showed that referrals declined during the COVID-19 pandemic and revealed differing underlying patterns of PC referral along disease groups. Understanding pre-existing referral patterns and lasting practice changes post-pandemic can support clinicians to integrate PC and improve cancer outcomes. Findings can be used to develop interventions, such as clinical triggers, to improve PC delivery for underserved cancer patients.

Factors associated with the receipt of palliative care in Native American patients with hepatocellular carcinoma: A retrospective analysis.

e16202 Background: Hepatocellular Carcinoma (HCC) is a leading cause of cancer-related deaths in the United States. This primary liver malignancy often has a poor prognosis and commonly metastasizes to the lungs, lymph nodes, bones, and adrenal glands. HCC has a high burden of disease with many patients suffering from discomfort and pain related to the disease and its treatment. Palliative care is a unique form of specialized care that provides relief, increasing comfort, and quality of life to patients suffering from illness. Many studies note its effectiveness in helping patients at any point in their illness. Furthermore, recent studies have shown that Native Americans face barriers to receiving palliative and end of life care. Thus, this study aims to examine the factors associated with receipt of palliative care within Native American HCC patients. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with Hepatocellular Carcinoma from 2004 to 2019 using the histology code 8170 and race code 03 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, ANOVA Chi-Square, and Cox Proportional Hazards tests were performed. Data was analyzed using SPSS version 28 and statistical significance was set at α = 0.05. Results: Out of 1536 Native American patients with HCC, 92 (5.9%) received palliative care. Patients who received palliative care experienced shorter mean survival than those who did not receive palliative care (15 vs 42 months; p &lt; 0.001). After controlling for age, year of diagnosis, surgical status and adjuvant therapies, not receiving palliative care was associated with an independent decrease in hazard (HR = 0.625, p &lt; 0.05). Palliative care patients were more likely to present with stage III and IV HCC, experience a longer delay in receiving treatment (69 vs 48 days) and have bone and lung metastasis when compared to those who did not receive palliative care (p &lt; 0.05). Patients who did not receive palliative care were more likely to have Medicare or Medicaid for insurance (p &lt; 0.05). There were no significant differences in the age, income bracket, facility type, tumor size or time to surgery between the patients who received palliative care and those who did not. Conclusions: This study found that patients with HCC are more likely to utilize palliative care if they have severe disease that metastasized to other organ systems. There is a higher mortality among patients who receive palliative care most likely because they had more severe disease. This research demonstrates the common trend of HCC patients underutilizing palliative care in the early stages of disease. Exploring the impacts early palliative care can have on HCC patients’ survival and quality of life would be valuable future areas of research.

Correlation of significant delays and ethnic disparities in the receipt of treatment, palliative care, and supportive care interventions in pancreatic adenocarcinoma.

e16355 Background: In patients with pancreatic adenocarcinoma (PDAC), immediate treatment initiation is preferred. Early palliative care initiation has also improved quality of life and symptom burden. However, the timing of real-world treatment and palliative care initiation and possible ethnic disparities are not well understood. The objective of this study was to evaluate the timing of care initiation in a mainly Hispanic population of PDAC patients. Methods: We conducted a retrospective cohort study that included patients diagnosed with PDAC from 2014 to 2023 at Loma Linda University Health (the only tertiary care center for two large Hispanic-majority counties with large rural populations). Data were obtained on the presence and timing of appropriate provider referrals, care establishment, treatment, advanced care planning, and hospital admissions. We used a Wilcoxon rank-sum test to compare Hispanic and non-Hispanic patients regarding the time to treatment initiation and palliative care initiation. Results: 263 PDAC patients were identified (mean age 66, 57% female, 47% Hispanic, 67% head tumor, 78% stage III/IV). After diagnosis, 93% of patients were referred to medical oncology, 82% to surgical oncology, 61% to palliative care, and 30% to genetic testing. An advanced directive or physician orders for life-sustaining treatment was completed for 24% of patients. The time to care initiation is as follows: a median of 23 days (IQR 14, 54) from diagnosis to the first medical oncology visit, 13 days (IQR 6, 37) to the first surgical oncology visit, 73 days (IQR 24, 132) to the first palliative care visit and 133 days (IQR 47, 329) to hospice referral. 64% of hospice referrals were placed within the last two weeks of life. Hispanic patients had a significantly longer time to treatment initiation (68 days vs. 48 days, p= 0.008) but similar times to palliative care initiation (73 vs 74 days, p= 0.64). Hispanics also had a lower rate of completing genetic testing (45% to 66%, p= 0.07). Conclusions: In our retrospective cohort study, significant delays in establishing care with oncology, palliative care, and hospice initiation in patients with PDAC were noted. Low rates of advanced care planning were also noted despite guideline recommendations for early-focused symptomatic interventions and advanced care planning. Hispanic patients had significantly longer time to treatment initiation and lower rates of genetic testing. These results indicate a need for improved targeted patient care navigation for multidisciplinary PDAC management, particularly in Hispanic patients.

Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure.

Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.

Behavioral economic interventions to embed early palliative care in community oncology (BE-EPiC): A pragmatic cluster-randomized trial.

Behavioral economic interventions to embed early palliative care in community oncology (BE-EPiC): A pragmatic cluster-randomized trial.

Patterns of referral to supportive oncology (SO) practice embedded in a cancer center and impact of timing of referrals on end-of-life outcomes.

e24064 Background: ASCO guidelines recommend early palliative care (PC) for patients with advanced cancer, defined as within eight weeks of diagnosis, to enhance survival and quality of life. It is unclear which subsets of patients are referred “late” to PC and how timing of referral impacts cancer outcomes and end-of-life care. Methods: Patients &gt;18 years with first SO consult between 01/01/2021-06/30/2023 were included. Data on patient demographics, acute healthcare and hospice utilization, cancer treatment and mortality was extracted from the electronic medical record (EMR) and claims database. Early referral to SO was defined as visit &lt; 3 months after diagnosis of advanced disease, delayed referrals &gt; 3 months and late consults as &lt; 30 days from death. We used descriptive statistics to describe patients’ sociodemographics, clinical characteristics and healthcare utilization. Multinomial logistic regression analysis was utilized to evaluate how patient characteristics influenced the timing of referrals. To examine the effects of late referral on inpatient (IP) and intensive care unit (ICU) stay durations, we applied a hurdle model. Results: Total sample included 1229 patients; majority had ECOG &lt; 2 and received one line of treatment at time of consult, 87% had solid tumors, of whom 74% had stage 4 disease. The solid tumors most referred were gastrointestinal cancers (25%), lung cancer (14%) and head and neck cancers (13%). Early referral rates across cancer groups differed significantly 53% Head and Neck, 48% GI, 46% Lung, 43% GYN, 29% GU, 11% Breast, and 31% Other (p &lt; 0.001). The most common reason for referral was physical symptom management (98%). The median ESAS symptom burden was 5 (range 0-10) symptoms. At time of analysis, 431 (35.1%) patients had died of which 256 (59%) were in-hospital deaths. Of the deceased patients, late referral ( &lt; 30 days from death) showed a trend, although not statistically significant, toward higher in-hospital mortality rates, (Odds Ratio: 1.13; 95% CI: 0.57-2.24), and a trend toward reduced likelihood of hospice enrollment(Odds Ratio: 0.73; 95% CI: 0.36-1.49). Notably, late referral significantly increased the duration of IP stays (p &lt; 0.001) and ICU stays (p = 0.004) in last 30 days of life, without change in admission to IP (p = 0.68) or ICU (p = 0.86). Conclusions: The delivery of the guideline-directed "early” consult among patients with advanced cancer is variable. Preliminary analysis showed a trend towards higher in-hospital mortality rates and lower hospice referral for patients referred &lt; 30 days from death among “late” consults. Further subgroup analysis is ongoing. [Table: see text]

Self-expressed needs and gaps in our care of metastatic breast cancer (MBC): An all-Ireland patient-led online survey (CTRIAL-IE 23-05).

12058 Background: Therapeutic advances have improved MBC survival rates, but patient self-expressed information needs have not been evaluated in Ireland to date. Heretofore, the patient’s voice has not been central to such an assessment, potentially leading to incorrect assumptions about MBC care. Methods: An anonymous online survey was designed by a cohort of 30 patients with MBC facilitated by a multidisciplinary breast cancer specialist taskforce. A questionnaire asked individuals to report their experience across three domains: credible information sources, palliative care access, and mental health. Patients with MBC 18 years or older living on the Island of Ireland were eligible to participate. The survey was publicised in the media and in oncology clinics nationally and was available for 10 weeks. The survey consisted of a mixture of open and closed questions and results were summarized by means of counts and percentages for categorical variables and by means of mean, standard deviation, median and range for continuous variables. Results: Between July-October 2023, 246 patients completed the survey. The median age of responders was 52.5. 99.4% of patients wished to have access to their personal medical records. Over 95% sought information about metastatic breast cancer outside of the clinic. The go-to information source varied (mostly online). No dedicated comprehensive information source on MBC was identified. Over 83% of patients with MBC were amenable to early palliative care referral but oncology teams did not raise this to the majority. Over 87% of patients reported mental health issues and the majority did seek support (88.4%). Living with uncertainty while awaiting scan results commonly led to feelings of anxiousness (79.5%), fearfulness (54.1%) and depression (15.2%). Conclusions: Patient-led research demonstrates that the patients’ voice is imperative to identify meaningful health interventions. System change including rapid streamlined access to personal medical records and the provision of a credible online information source dedicated to MBC may empower patients to enable them to live well for as long as possible. Routine discussion around early palliative care referral and an opt out approach may be of benefit. Acknowledging the high burden of mental health issues among this patient group and ongoing development of support services is crucial. Minimising the time patients live with uncertainty waiting for scan results should be prioritised.

Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study.

Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.

Characteristics and Effectiveness of Individual Psychotherapy for Palliative and End-of-Life Care: A Literature Review for Randomized Controlled Trials.

The introduction of psychotherapy in palliative and end-of-life care settings has become increasingly common and is effective in decreasing many psychological problems. This review reports the characteristics and effectiveness of individual psychotherapeutic interventions for patients receiving palliative and end-of-life care. In addition, the review reports the effectiveness of psychotherapies considering the expected life expectancy. The PubMed, Google Scholar, and Cochrane Library databases were searched for English-language articles published between January 2000 to May 2023. Twenty-six studies were included and classified into a total of nine types of psychotherapies, namely, dignity therapy (DT), life review therapy, narrative therapy, managing cancer and living meaningfully (CALM), individual meaning-centered psychotherapy, meaning and purpose therapy, meaning-making therapy, meaning-of-life therapy, and cognitive therapy. Most of the psychotherapies provided to patients receiving palliative and end-of-life care showed effectiveness in the reduction of negative emotions and positive factors related to end-of-life issues. Most studies targeted patients with advanced cancer; however, studies on DT did not limit the target group to patients with cancer. Considering the expected life expectancy, CALM was found to be suitable for patients receiving early palliative care.

Qualitative evaluation of motives for acceptance or refusal of early palliative care in patients included in early-phase clinical trials in a French comprehensive cancer center: the PALPHA study.

The integration of palliative care (PC) into oncological management is recommended well before the end of life. It improves quality of life and symptom control and reduces the aggressiveness of end-of-life care. However, its appropriate timing is still debated. Entry into an early-phase clinical trial (ECT) represents hopes for the patient when standard treatments have failed. It is an opportune moment to integrate PC to preserve the patient's general health status. The objective of this study was to evaluate the motives for acceptance or refusal of early PC management in patients included in an ECT. Patients eligible to enter an ECT were identified and concomitant PC was proposed. All patients received exploratory interviews conducted by a researcher. Their contents were analyzed in a double-blind thematic analysis with a self-determination model. Motives for acceptance (PC acceptors: n = 27) were both intrinsic (e.g., pain relief, psychological support, anticipation of the future) and extrinsic (e.g., trust in the medical profession, for a relative, to support the advance of research). Motives for refusal (PC refusers: n = 3) were solely intrinsic (e.g., PC associated with death, negative representation of psychological support, no need for additional care, claim of independence). The motives of acceptors and refusers are not internalized in the same way and call for different autonomy needs. Acceptors and refusers are influenced by opposite representations of PC and a different perception of mixed management.

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 palliative care perceptions by patients with cancer and primary caregivers: metaphorical language

ObjectiveThis article reports on the results of an analysis of metaphorical language used by patients diagnosed with advanced cancer and their caregivers receiving early palliative care (EPC).MethodsData were collected through...

De-escalating treatments and transitioning care in a cardiac intensive care units network

Abstract Funding Acknowledgements None. Background Recent data (1) have shown that end-of-life (EOL) management of patients with acute decompensated heart failure (ADHF) in Cardiac Intensive Care Units (CICU) is aggressive, with late or no involvement of palliative care (PC) teams. Purpose To evaluate current PC and EOL practices in a contemporary multicenter registry of patients with ADHF who deteriorated to cardiogenic shock (CS). Methods A survey-based approach was used to collect data on PC and EOL management practices. We enrolled CS patients from 12 participating centers. A subset of 153 patients with ADHF-CS, enrolled between March 2020 and March 2023, was analyzed. We asked participating centers to report their practice regarding de-escalating treatments and transitioning care in the context of EOL, focusing on 1) discussion of implantable cardioverter defibrillator (ICD) deactivation with patients, 2) documentation of do-not-resuscitate (DNR) orders in the patient's medical record, and 3) documentation of advance directives in the patient's medical record. We also examined early PC team involvement and ICD deactivation as indicators of de-escalating treatments and transitional care in ADHF-CS. Results are presented as numbers and percentages (%) for categorical variables and medians (interquartile range, IQR) for continuous variables. Results Baseline characteristics of the population are shown in Table 1. Figure 1 describes the practices of the participating centers. DNR was routinely documented in the medical records in only 5 of 12 centers (41.7%). PC teams were involved in 21 of 153 enrolled ADHF-CS patients (13.7%). Of the 51 patients with an ICD, 17 died: 13 patients (76%) died in the hospital and 4 (24%) died within 6 months of discharge. ICD deactivation occurred in 6 of 17 deceased patients (35.3%). One patient had ICD deactivation supported by home PC services. Conclusions This study shows that the practice of de-escalating therapy, including ICD deactivation, is not routine in the participating centers. Our findings highlight the importance of integrating PC as a concurrent process with intensive care to effectively address the unmet needs of these patients and their families.

“If we don't speak the language, we aren't offered the same opportunities”: Qualitative perspectives of palliative care access for women of color living with advanced breast cancer

ContextDespite efforts to enhance equity, disparities in early palliative care (PC) access for historically minoritized patients with advanced breast cancer (ABC) persist. Insight into patient and clinician perspectives are needed to inform future models aimed at improving equity in PC access and outcomes. ObjectivesTo explore qualitative barriers and facilitators to early PC access in an urban setting with Black and Latina women with ABC. MethodsIn this qualitative descriptive study, we conducted one-on-one interviews with Black and Latina women with ABC (N = 20) and interdisciplinary clinicians (N = 20) between February 2022 and February 2023. Participants were recruited from urban academic and community cancer clinics. Transcripts were analyzed using an inductive coding and thematic analysis approach. ResultsBarriers identified by both patients and clinicians included lack of communication between oncology, PC, and primary care teams, limited understanding of PC among patients and non-PC clinicians, language and health literacy-related communication challenges, and racism and marginalization, including implicit bias and lack of diverse racial/ethnic representation in the supportive care workforce. Facilitators identified by both patients and clinicians included patient-to-patient referrals, support groups breaking cultural stigma on topics including self-advocacy and PC, referrals from trusted providers, and community organizations’ abilities to overcome challenges related to social determinants of health, most specifically logistical and financial support. ConclusionsPatients and clinicians reported similar barriers and facilitators to PC access, most commonly through the lens of care coordination and communication. These findings will inform future adaptation of a culturally and linguistically care model to improve access to early PC services for Black and Latina women with ABC.

Effectiveness of early palliative care in patients with head and neck cancer in Taiwan.

Early palliative care (EPC) benefits some cancers, but its clinical outcomes differ depending on patients' racial and ethnic disparities, and customs. To determine whether EPC improves symptoms, emotional distress, and quality of life among Taiwanese patients with early or advanced-stage head and neck cancer (HNC). Based on participants' pathological stages, they were categorized as having early and advanced-stage HNC. Those willing and unwilling to undergo EPC were assigned to the EPC and standard groups, respectively. Their daily cancer-related symptoms were assessed using the Distress Thermometer (DT) and MD Anderson Symptom Inventory (MDASI), whose scores' concurrent validity was evaluated using the European Organization for Research and Treatment of Core Quality of Life (EORTC-QLQ-C30) and Head and Neck 35 (EORTC-QLQ-H&N35) questionnaires. Patients (n = 93) diagnosed with HNC at Taiwan's Chia-Yi Christian Hospital from November 2020 to October 2022 were recruited. The patients voluntarily split into two groups: EPC groups and standard groups (23 and 11 in early-stage; 46 and 13 in advanced-stage, respectively). DT assessment showed significant emotional distress improvements for all patients with HNC who received EPC. The EORTC-QLQ-C30 questionnaire indicated that, compared to standard interventions, EPC groups significantly improved the quality of life and some symptoms for both early and advanced-stage HNC patients. However, the EORTC-QLQ-H&N35 questionnaire found no significant difference between the two groups. Furthermore, advanced-stage patients' anticancer treatment completion rates with EPC and standard interventions were 95.35% and 75%, respectively. EPC improves symptoms, emotional distress, quality of life, and treatment completion rates in Taiwanese patients with early or advanced-stage HNC. Nonetheless, further extensive clinical studies are required for validation.