Intensity Of End-of-life Care Research Articles

Timing of Palliative Care Consultation and End-of-Life Care Intensity in Pediatric Patients With Advanced Heart Disease: Single-Center, Retrospective Cohort Study, 2014-2022.

Pediatric patients with advanced heart disease (AHD) often receive high intensity medical care at the end of life (EOL). In this study, we aimed to determine whether receipt and timing of pediatric palliative care (PPC) consultation was associated with EOL care intensity of pediatric patients with AHD. Retrospective cohort study. Single-center, 16-bed cardiac ICU (CICU) in a children's hospital in the Mountain West. Pediatric patients (0-21 yr) with AHD treated in the CICU and subsequently died from January 2014 to December 2022. None. We compared demographics, EOL characteristics and care, including medical interventions and mortality characteristics for patients by receipt and timing of PPC (i.e., ≥ 30 d from [early] or < 30 d of death [late]) using chi-square and Wilcoxon rank-sum tests. Of 218 patients, 78 (36%) did not receive PPC, 76 received early PPC (35%), and 64 received late PPC (29%). Compared with patients who did not receive PPC, patients receiving PPC had lower EOL care intensity (77% vs. 96%; p = 0.004) and fewer invasive interventions within 14 days of death (74% vs. 92%; p = 0.004). Receipt of PPC, vs. not, was associated with lower rate of death during cardiopulmonary resuscitation (12% vs. 32%; p = 0.004) and more use of comfort care (23% vs. 3%; p = 0.004). Among patients receiving PPC, early PPC was associated with fewer invasive interventions within 14 days of death (65% vs. 85%; p = 0.033). Care intensity was high for patients with early and late PPC. Early PPC was associated with fewer invasive interventions within 14 days of death, yet the care intensity at EOL remained high. With early PPC, families likely receive timely psychosocial and advance care planning support without significantly altering goals of care.

Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study.

Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients. We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care. Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death. Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.

Programmatic Palliative Care Consultations in Pediatric Heart Transplant Evaluations.

Guidelines advocate for integrating palliative care into the management of heart failure (HF) and of children with life-limiting disease. The potential impact of palliative care integration into pediatric HF on patient-centered outcomes is poorly understood. The present study sought to assess the association of programmatic implementation of palliative care into the heart transplant evaluation process with hospital-free days (HFD) and end of life (EOL) treatment choices. The study included patients less than 19 years of age who underwent a heart transplant evaluation between February 2012 and April 2020 at a single center. Patients evaluated in the programmatic palliative care (PPC) era (January 2016-April 2020) were compared to patients evaluated in the pre-PPC era (February 2012-December 2015). The study included 188 patients, with 91 (48%) in the PPC era and 97 (52%) in the pre-PCC era. Children < 1 year of age at the time of the evaluation represented 32% of the cohort. 52% of patients had single ventricle physiology. PPC was not significantly associated with increased HFD (IRR 0.94 [95% CI 0.79-1.2]). PPC was however associated with intensity of EOL care with decreased mechanical ventilation (OR 0.12 [95% CI 0.02-0.789], p = 0.03) and decreased use of ionotropic support (OR 0.13 [95% CI 0.02-0.85], p =0.03). PPC in pediatric heart transplant evaluations may be associated with less invasive interventions at EOL.

The Effect of Specialized Palliative Care on End-of-Life Care Intensity in AYAs with Cancer.

Many adolescents and young adults (AYAs; 15-39 years) with cancer receive high intensity (HI) care at the end of life (EOL). Palliative care (PC) involvement in this population is associated with lower risk of HI-EOL care. Whether this association differs by specialized vs. generalist PC (SPC, GPC) is unknown. (1) To evaluate whether SPC had an impact on the intensity of EOL care received by AYAs with cancer; (2) to determine which subpopulations are at highest risk for reduced access to SPC. A decedent cohort of AYAs with cancer who died between 2000-2017 in Ontario, Canada was identified using registry and population-based data. The primary composite measure of HI-EOL care included any of: intravenous chemotherapy <14 days from death; more than one ED visit, more than one hospitalization or any ICU admission <30 days from death. Physician's billing codes were used to define SPC and GPC involvement. Of 7122 AYA decedents, 2140 (30%) received SPC and 943 (13%) received GPC. AYAs who died in earlier years, those with hematologic malignancies, males and rural AYAs were least likely to receive SPC. No PC involvement was associated with higher odds of receiving HI-EOL care (odds ratio (OR) 1.5; P < 0.0001). SPC involvement was associated with the lowest risk of HI-EOL care (OR SPC vs. GPC 0.8; P=0.007) and decreased odds of ICU admission (OR 0.7; P=0.006). SPC involvement was associated with the lowest risk of HI-EOL care in AYAs with cancer. However, access to SPC remains a challenge.

Abstract A037: Exploring disparities in the provision of child life legacy and bereavement services at SJCRH: Decedent cohort review

Abstract Disparities in end-of-life (EOL) care have been documented across cancer populations. For pediatric oncology patients, disparities in intensity of EOL care have been correlated with income, race, and ethnicity. However, less is known about disparities in psychosocial services provided at EOL for children with cancer. Child life specialists (CLS) work with pediatric oncology patients and families at EOL to provide key legacy interventions to offer support and mitigate complex bereavement. Presently, little is known about disparities in provision of these psychosocial services to children with cancer at EOL. In this retrospective decedent cohort study, we aimed to explore differences in receipt of legacy building services for children with cancer, stratified by race, ethnicity, primary language, diagnosis, and location of death. Using a comprehensive standardized tool, we abstracted data from the electronic medical record for 676 pediatric oncology patients who received care at a single academic pediatric cancer center and died between 2015 and 2019. More than half (52.1%) of patients/families received a legacy intervention during the illness course, at end of life, or following death. The most common legacy interventions included provision of a legacy item alongside a bereavement service (29.2%) or provision of a legacy item only (10.8%). Through univariate analysis, no racial disparities in legacy intervention provision were identified. Hispanic/Latino patients were more likely to receive legacy interventions compared to non-Hispanic patients (60.8% vs. 50.4%, p = 0.0474). Families who spoke Spanish were more likely to receive legacy and bereavement studies than those who spoke English or other languages (65.8% vs. 50.6% vs. 44.4%, p = 0.0317). Patients with brain tumors were less likely to receive legacy interventions compared to patients with hematologic malignancies or solid tumors, (32.0% vs. 35.1% vs. 32.9%, p &amp;lt; 0.001). Brain tumor patients were also more likely to die at home compared to patients with hematologic malignancies or solid tumors (52.5% vs. 11.2% vs. 37.6%, p &amp;lt; 0.001), suggesting that location of death may influence access to legacy interventions. These findings will inform the development and testing of targeted strategies to improve access to and provision of legacy interventions for all children with advanced cancer and their families. Citation Format: Sarah Daniels, Erica C. Kaye, Suraj S. Mothi, Libby Gaitskill, Kathryn Cantrell, Nelson D. Franqui-Ríos. Exploring disparities in the provision of child life legacy and bereavement services at SJCRH: Decedent cohort review [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A037.

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

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

Comparison of Advance Care Planning and End-of-Life Care Intensity Between Dementia Versus Cancer Patients.

While advanced care planning (ACP) is recommended in dementia and cancer care, there are unique challenges in ACP for individuals with dementia, such as the insidious onset and progression of cognitive impairment, potentially leading to high-intensity care at the end of life (EOL) for this population. To compare ACP completion and receipt of high-intensity care at the EOL between decedents with dementia versus cancer. Retrospective longitudinal cohort study. Participants of the U.S. Health and Retirement Study who died between 2000 and 2014 with dementia (n = 2099) and cancer (n = 1137). Completion of three types of ACP (living will, durable power of attorney for healthcare [DPOAH], discussions of preferences for EOL care) and three measures of EOL care intensity (in-hospital death, intensive care unit [ICU] care in the last 2 years of life, life support use in the last 2 years of life). Use of living will was lower in dementia than in cancer (adjusted proportion, 49.9% vs. 56.9%; difference, - 7.0 percentage points [pp, 95% CI, - 13.3 to - 0.7]; p = 0.03). Use of DPOAH was similar between the two groups, but a lower proportion of decedents with dementia had discussed preferences compared to decedents with cancer (53.0% vs. 68.1%; - 15.1 pp [95% CI, - 19.3 to - 10.9]; p < 0.001). In-hospital death was higher in dementia than in cancer (29.5% vs. 19.8%; + 9.7 pp [95% CI, + 5.9 to + 13.5]; p < 0.001), although use of ICU care was lower (20.9% vs. 26.1%; - 5.2 pp [95% CI, - 9.8 to - 0.7]; p = 0.03). Use of life support was similar between the two groups. Individuals with dementia complete ACP less frequently and might be receiving higher-intensity EOL care than those with cancer. Interventions targeting individuals with dementia may be necessary to further improve EOL care for this population.

End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation.

Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.

Care at the end of life during the COVID-19 pandemic: A CancerLinQ Discovery (CLQD) analysis.

310 Background: For patients with cancer approaching end-of-life (EOL) during the COVID-19 pandemic, the changes in service availability and transition to telehealth may impact care delivery. Little is known about how the COVID-19 pandemic impacted EOL encounters with the healthcare system, particularly for vulnerable patient populations. Methods: This retrospective cohort study included patients with cancer who died from 1/2019-9/2020 in the CLQD electronic health record-based dataset. Descriptive statistics were generated for demographic characteristics and for clinical encounters (telehealth/in person/no encounter) in the last 3 months of life (EOL) among patients deceased in the year. Results were stratified by age, race, ethnicity, and geographic region. Results: Among the 49,688 deceased patients, 27% were under 65, 29% were 65-74, and 44% were 75+. The majority were Non-Hispanic White, with 5% Hispanic, 12% Black. In 2020, patients who were age 75+, White, Non-Hispanic, and/or living in the Midwest or Northeast had lower rates of in person encounters and higher rates of no encounter at EOL than those &lt;65, Black, Hispanic, and/or living in the South (Table). Telehealth use at EOL increased from 2019 to 2020, with highest use amongst those in the West and Hispanic patients (Table). Conclusions: During the pandemic, telehealth use was limited at EOL compared to the 14% reported use for all cancer patients (data not shown). Black and Hispanic patients had slightly higher provider encounters at EOL, which may be due to differences in intensity of EOL care or death capture within the database. Further research is needed to evaluate the quality of EOL care and to assess opportunities to leverage telehealth where patients are unable to access outpatient services.[Table: see text]

Impact of the Oncology Care Model on End‐of‐Life Care

Research ObjectiveThe Oncology Care Model (OCM) is a six‐year episode‐based alternative payment model for cancer care launched by the Centers for Medicare &amp; Medicaid Services in July 2016. OCM includes several elements intended to improve end‐of‐life (EOL) care. We evaluated the impact of OCM on EOL care intensity, spending, and oncologist and patient experiences.Study DesignUsing 100% Medicare claims (2014–2019) we employed a Difference‐in‐Differences (DID) approach comparing changes over time in care intensity and Medicare payments at the end of life, for beneficiaries served by OCM practices and by a propensity‐score matched comparison group of non‐participating practices. We also surveyed caregivers of deceased beneficiaries about patient experiences in the last month of life, and we surveyed oncologists from OCM practices about changes in palliative and EOL care. Finally, we conducted case studies with over 40 OCM practices.Population StudiedClaims‐based analyses included 256,102 Medicare beneficiaries in OCM or comparison practices who underwent chemotherapy for cancer and died during or within 90 days of their last OCM‐defined episode. Surveys were completed by family members of 5786 deceased beneficiaries (55% OCM, 45% comparison) and by 400 oncologists working in OCM practices.Principal FindingsOCM led to fewer hospitalization in the last 30 days of life for deceased OCM versus comparison beneficiaries (DID:‐11 per 1000 beneficiaries (90%CI:‐19, −4). OCM had no impact on outpatient emergency department use in the last month of life, use of infused chemotherapy in the last two weeks of life, or on hospice use, duration, or timing.The average Medicare Part A payments during the last episode for deceased beneficiaries rose $440 less in the OCM group than in comparisons, a 2.4 percent relative reduction from the OCM baseline mean of $18,530 (p ≤ 0.05). OCM had no impact on average total episode payments, or on Medicare Part B or D payments, during deceased beneficiaries' last episodes.OCM did not affect caregivers' perceptions: survey respondents rated EOL care highly before OCM began, and there were no changes over time and no differences between OCM and comparison respondents. Roughly one third of oncologists reported enhancing access to palliative care (36%) and using new/enhanced standards or guidelines to trigger discussions about EOL goals and hospice (32%). Most oncologists (55%) reported that OCM improves quality of EOL care.ConclusionsOCM led to a small relative reduction in hospitalizations during deceased beneficiaries' last month of life and a corresponding relative decrease in Medicare Part A payments. OCM had no impact on hospice use, duration, or timing. OCM had no impact on beneficiaries' care experiences at the end of life. Oncologists reported EOL process improvements attributable to OCM.Implications for Policy or PracticeOCM emphasizes shared decision making and advance care planning to ensure that cancer beneficiaries' EOL wishes are documented and followed. The first three years of OCM suggest that these efforts led to small relative reductions in hospitalizations and Part A payments in the last month of life. The lack of impact on hospice use/timing, despite clinician‐reported EOL care process improvements, suggests ongoing areas for potential improvements.Primary Funding SourceCenters for Medicare and Medicaid Services.

Impact of Palliative Care Involvement on End-of-Life Care Patterns Among Adolescents and Young Adults With Cancer: A Population-Based Cohort Study.

Evidence suggests that adolescents and young adults (AYAs) with cancer (defined as age 15-39 years) receive high-intensity (HI) medical care at the end-of-life (EOL). Previous population-level studies are limited and lack information on the impact of palliative care (PC) provision. We evaluated prevalence and predictors of HI-EOL care in AYAs with cancer in Ontario, Canada. A secondary aim was to evaluate the impact of PC physicians on the intensity of EOL care in AYAs. A retrospective decedent cohort of AYAs with cancer who died between 2000 and 2017 in Ontario, Canada, was assembled using a provincial registry and linked to population-based health care data. On the basis of previous studies, the primary composite measure HI-EOL care included any of the following: intravenous chemotherapy < 14 days from death, more than one emergency department visit, and more than one hospitalization or intensive care unit admission < 30 days from death. Secondary measures included the most invasive (MI) EOL care (eg, mechanical ventilation < 14 days from death) and PC physician involvement. We determined predictors of outcomes using appropriate regression models. Of 7,122 AYAs, 43.8% experienced HI-EOL care. PC physician involvement (odds ratio [OR], 0.57; 95% CI, 0.51 to 0.63) and older age at death (OR, 0.60; 95% CI, 0.48 to 0.74) were associated with a lower risk of HI-EOL care. AYAs with hematologic malignancies were at highest risk for HI and MI-EOL care. PC physician involvement substantially reduced the odds of mechanical ventilation at EOL (OR, 0.36; 95% CI, 0.30 to 0.43). A large proportion of AYAs with cancer experience HI-EOL care. Our study provides strong evidence that PC physician involvement can help mitigate the risk of HI and MI-EOL care in AYAs with cancer.

Exploratory Study Comparing End-of-Life Care Intensity between Chinese American and White Advanced Cancer Patients at an American Tertiary Medical Center.

Background: Understanding ethnic disparities in end-of-life care (EOLC) intensity is central to improving outcomes for diverse populations. Although Chinese Americans represent one of the fastest growing ethnic groups in the United States, little is known about their EOLC intensity.Objective: To explore differences in indicators of high-intensity EOLC in the final 30 days of life, place of death, and hospice utilization between Chinese American and White advanced cancer patients.Methods: In this exploratory review, we collected data on 48 Chinese American and 48 White stage IV solid tumor patients who died during 2013–2018. Indicators of high-intensity care from the final 30 days of life included ≥2 hospital, ≥1 intensive care unit (ICU), and/or ≥2 emergency department admissions; cardiopulmonary resuscitation administration and mechanical ventilation (MV); place of death; and whether patients were on hospice at death.Results: Among Chinese American and White patients, respectively, 49% and 36% died in the hospital, 15% and 7% died in the ICU, 17% and 8% received MV, and 6% and 13% had ≥1 hospital admission lasting >14 days. Seventeen percent of Chinese American and 43% of White patients died at home. Hospice enrollment was similar between groups. Seventeen percent of Chinese American and 8% of White patients died within 30 days of diagnosis.Conclusion: Results suggest that fewer Chinese Americans died at home, whereas more died in the ICU, received MV, and died within 30 days of cancer diagnosis, indicating possible disparities in EOLC. Further studies are needed to explore findings from this exploratory investigation.

High-Intensity End-of-Life Care Among Patients With GI Cancer in Puerto Rico: A Population-Based Study.

PURPOSE:High-intensity care with undue suffering among patients with cancer at the end of life (EoL) is associated with poor quality of life. We examined the pattern and predictors of high-intensity care among patients with GI cancer in Puerto Rico.METHODS:This population-based study of data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database examined patients with GI cancer who died between 2009 and 2017. EoL care intensity indicators include the following services in the last month before death: emergency room (ER) visits, hospitalizations, intensive care unit (ICU) admissions, life-extending procedures, death in an acute care setting, and the use of chemotherapy in the last 14 days. We used logistic regression models to examine factors associated with EoL care.RESULTS:Four thousand six hundred twenty-nine patients with GI cancer were included in the analysis. We found that 11.0% of patients received chemotherapy, 17.3% had > 1 hospitalization, 9.3% were in the ICU, 18.0% had > 1 ER visit, 39.3% died in an acute care setting, and 8.6% received life-extending procedures. A compound indicator of the aggressiveness of care showed that 54.5% of patients had at least one of the selected aggressive indicators. The multivariable model showed that female patients, patients ≥ 60 years of age, patients enrolled in Medicaid, patients dually eligible for both Medicare and Medicaid, and patients who survived > 1 year were less likely to receive aggressive EoL care.CONCLUSION:Our findings support the urgent need to improve EoL care in Puerto Rico. Further studies are warranted to fully understand EoL care in patients with cancer in Puerto Rico.

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

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

Associations Between Health Literacy and End-of-Life Care Intensity Among Medicare Beneficiaries.

Despite well-documented disparities in end-of-life (EOL) care, little is known about whether patients with low health literacy (LHL) received aggressive EOL care. This study examined the association between health literacy (HL) and EOL care intensity among Medicare beneficiaries. We conducted a retrospective analysis of Medicare fee-for-service decedents who died in July-December, 2011. ZIP-code-level HL scores were estimated from the 2010-2011 Health Literacy Data Map, where a score of 225 or lower was defined as LHL. Aggressive EOL care measures included repeated hospitalizations within the last 30 days of life, no hospice enrollment within the last 6 months of life, in-hospital death, and any of above. Using hierarchical generalized linear models, we examined the association between HL and aggressive EOL care. Of 649,556 decedents, the proportion of decedents who received any aggressive EOL care among those in LHL areas was 82.7%, compared to 72.7% in HHL areas. In multivariable analyses, decedents residing in LHL areas, compared to those in HHL areas, had 31% higher odds of aggressive EOL care (adjusted odds ratio [AOR] 1.31; 95% confidence interval [CI]:1.21-1.42), including higher odds of no hospice use (AOR 1.35; 95% CI: 1.27-1.44), repeated hospitalization (AOR 1.07; 95% CI: 1.01-1.14) and in-hospital death (AOR 1.21; 95% CI: 1.13-1.29). Medicare beneficiaries who resided in LHL areas were likely to receive aggressive EOL care. Tailored efforts to improve HL and facilitate patient-provider communications in LHL areas could reduce EOL care intensity.

Intensity of End-of-Life Care in a Cohort of Commercially Insured Women With Metastatic Breast Cancer in the United States.

There is limited evidence on the intensity of end-of-life (EOL) care for women < 65 years old, who account for about 40% of breast cancer deaths in the United States. Using established indicators, we estimated the intensity of EOL care among these women. We used 2000-2014 claims data from a large US insurer to identify women with metastatic breast cancer who, in the last month of their lives, had more than one hospital admission, emergency department visit, or an intensive care unit (ICU) admission and/or used antineoplastic therapy in the last 14 days of life. Using multivariate logistic regression, we assessed whether intensity of EOL care differed by demographic characteristics, socioeconomic factors, or regions. Adjusted estimates show an increase in EOL ICU admissions between 2000-2003 and 2010-2014 from 14% (95% CI, 10% to 17%) to 23% (95% CI, 20% to 26%) and a small increase in emergency department visits from 10% (95% CI, 7% to 13%) to 12% (95% CI, 9% to 15%), both statistically significant. There was no statistically significant change in the proportions of women experiencing more than one EOL hospitalization (14% in 2010-2014; 95% CI, 11% to 17%) and of those receiving EOL antineoplastic treatment (24% in 2010-2014; 95% CI, 21% to 27%). Living in predominantly mixed, Hispanic, Black, or Asian neighborhoods correlated with more intense care (odds ratio, 1.39; 95% CI, 1.10 to 1.77 for ICU). Consistent with findings in the Medicare population, our results suggest an overall increase in the number of ICU admissions at the EOL over time. They also suggest that patients from non-White neighborhoods receive more intense acute care.

The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study.

Little is known about the relationship between loneliness and end-of-life (EOL) experience including symptom burden, intensity of care, and advance care planning among older adults. Secondary analysis of the Health and Retirement Study (HRS). Population based. Decedents older than 50 years who died between 2004 and 2014 (n = 8700). Exclusions included those who were ineligible for surveys assessing loneliness (n = 2932) or had missing or incomplete loneliness or symptom data (n = 2872). Individuals were characterized as lonely based on responses to the three-item Revised University of California, Los Angeles Loneliness Scale in the most recent HRS survey before death. Outcomes were proxy reports of total EOL symptom burden, intensity of EOL care (eg, late hospice enrollment, place of death, hospitalizations, use of life support), and advance care planning. Results were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). One-third of 2896 decedents (n = 942) were lonely. After adjusting for demographics, socioeconomic status, multimorbidity, depressive symptoms, family and friends, and social support, loneliness was independently associated with increased total symptom burden at EOL (ß = .13; P = .004). Compared with nonlonely individuals, lonely decedents were more likely to use life support in the last 2 years of life (35.5% vs 29.4%; aOR = 1.36; 95% CI = 1.08-1.71) and more likely to die in a nursing home (18.4% vs 14.2%; aOR = 1.78; 95% CI = 1.30-2.42). No significant differences in other measures of intense care (late hospice enrollment, number of hospitalizations, or dialysis use) or likelihood of advance care planning were observed. Lonely older people may be burdened by more symptoms and may be exposed to more intense EOL care compared with nonlonely people. Interventions aiming to screen for, prevent, and mitigate loneliness during the vulnerable EOL period are necessary. J Am Geriatr Soc 68:1064-1071, 2020.

Multiple chronic conditions and intensity of end-of-life care among patients with cancer.

47 Background: Multiple chronic conditions (MCCs) are associated with increased intensity of end-of-life (EOL) care in many conditions but their effect has not been well explored in patients with cancer. We examined intensity of EOL care and advance care planning (ACP) by patients with cancer and MCCs versus those without MCCs to better understand how MCCs affect EOL healthcare use in this population. Methods: Our sample included patients with cancer in the UW Medicine system who died between 2010-2017. MCCs were defined using the Dartmouth Atlas of Healthcare for the most common categories of severe illness in the last two years of life. These included chronic pulmonary disease, coronary artery disease (CAD), heart failure, severe chronic liver disease, chronic renal disease, dementia, diabetes with end organ damage, or peripheral vascular disease. Patients were categorized as having none or 1+ MCCs. We used a claims-based indicator for the presence of functional limitation. Outcomes included ACP documentation in the electronic health record, death in hospital, and inpatient or ICU admission in the last month of life. We performed logistic regression for all outcomes controlling for confounders defined a priori (age at death, race, sex, marital status, insurance, education, functional limitation). Results: Of 15,092 patients with cancer, 10,596 (70%) had 1+MCCs (range 1-8 MCCs). Common MCCs were pulmonary (25%), CAD (23%), and renal (18%). Those with MCCs were older (median 66 years (range 18-104) vs 63 years (range 18-102)), with more functional limitations (65% vs 43%). Those with 1+ MCC had more ACP documentation (43% vs. 23%) compared to those with no MCCs. Patients with 1+ MCC were more likely to die in hospital (OR 1.86, 95% CI 1.72-2.02) and to have inpatient (OR 2.45, 95% CI 2.20-2.72) or ICU admissions (OR 2.95, 95% CI 2.55-3.42) in their last 30 days versus patients with cancer and no MCCs. Conclusions: Among patients with cancer in a single healthcare system, patients with cancer and MCCs were more likely to have ACP documentation, die in hospital and experience high-intensity hospital-based care at or near EOL. Further research is needed to explore if such high-intensity care is aligned with patient and family goals for care.

Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy

ContextPatients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown. ObjectivesTo assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis. MethodsWe performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression. ResultsDuring the last year of life, patients had a median of three hospitalizations (IQR 2–5) and spent a median of 31 days (IQR 16–49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049). ConclusionPatients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.

Intensity of Care at End-of-Life in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Introduction Allogeneic hematopoietic cell transplant (HCT) recipients are at a high risk for morbidity and mortality. The literature on quality and intensity of end of life (EOL) care and its association with advance directives and palliative involvement in this population is sparse. Objectives We sought to describe the EOL care in a cohort of allogeneic HCT patients who died and examine its association with advance directives, palliative care involvement, and patient characteristics. Methods A retrospective review of the medical record of patients who had received their allogeneic HCT (n=368) at our institution between 2013 and 2017 and died (n=129) was performed to collect information on place of death, hospital length of stay, number of admissions, intensity of care and palliative/ chaplain referrals. High intensity EOL care was defined as >1 of the following: death in the hospital, invasive procedure in the last week of life, use of mechanical ventilation in the last week of life, change to ‘no resuscitation’ code status in the last 3 days of life, length of stay >14 days in the last hospitalization, and >50% of last hospitalization in ICU. Association between baseline characteristics (age, gender, disease, disease risk, education, race/ ethnicity), presence of a living will and palliative medicine consult with intensity of EOL care was examined by a multivariable logistical model. Results Out of 129 deaths, 83(64%) had received EOL care at our institution and were included in the analysis. Median age of the patients in the cohort was 60 (range 21 to 76) years, 64% were male, 89% were white, 32% had received college or higher education and 66% had private insurance. 59% patients died in hospice (36% in inpatient hospice, and 23% in home hospice) and 40% in the hospital (23% in ICU and 17% on the floor). Figure shows indicators of intense EOL care in patients who died in hospital vs. hospice. Median duration of hospice was 3 (range 1-41) days. 72% had an advance directive on record and 37% were seen by palliative medicine. There was a higher rate of mechanical ventilation (p 1 intensive care indicators. Conclusions There is a high utilization of intensive care and procedures in the last days of life for patients dying in the hospital. Patients with advance directives were more likely to experience a value based EOL care including avoidance of intensive, and ultimately futile, medical care.