Hospice Facility Research Articles

Multimodal Interventions Improve Stroke Recovery.

According to this study.

Palliative Radiation for Bone Metastases: Reconsidering the Optimal Timing

Bone metastases impair function and decrease quality of life due to acute or chronic pain. The standard approach for patients with multiple bone metastases is systemic therapy and palliative radiation therapy (RT) when the metastases become symptomatic. This study aims to understand the characteristics and outcomes for inpatients admitted for painful bone metastases. An inpatient radiation oncology consult registry was created in 2015 to evaluate patterns of care for patients receiving RT in the inpatient setting. Of the 1151 consults requested between 7/2015 and 6/2016, 28% (n = 319) were for evaluation of symptomatic bone metastases in patients who were hospitalized for acute or chronic pain. Two hundred eight patients went on to receive RT to 224 bone metastases. Sixty-one percent of RT courses were initiated while the patient was hospitalized. Clinical characteristics correlated with overall survival (OS) were evaluated through Cox regression analysis. The median follow-up of the patients who received RT from the time of consult was 4.9 months (0.1-19.6 months). Median age for patients who received RT was 61 (22-93 years) and median KPS 70 (40-90). The most common histology was lung (n = 51), followed by prostate (n = 34), non-prostate genitourinary (n = 34), gastrointestinal (n = 32), and breast (n = 22). The most common sites to be treated were spine (51%), joints such as hip and shoulder (11%), long bones including femur and humerus (11%), and pelvis (11%). Of the irradiated painful lesions, 60% (n = 134) were present on imaging ≥4 months prior to RT. The median survival from the initiation of palliative RT was 4.6 months (0.03-19.3 months). Among the 140 patients who had died at the time of analysis, 79 (56%) died within 2 months after RT, and 125 (89%) within 6 months. Eighteen patients (9%) discontinued RT to transition to hospice care. Thirty-seven patients (26%) died in the hospital, while 65 (46%) died at home and 38 (27%) died at an inpatient hospice facility. OS after RT is significantly correlated with KPS at the time of consult (P = .02) but not with the age of the patient or site of treated disease. In this select group of inpatients who were evaluated for palliation of symptomatic bone metastases, we found a short OS after RT. The majority of metastases were present for ≥4 months prior to RT. This study suggests that there may be a role for earlier RT to bone metastases to prevent development of symptomatic disease that requires hospitalization. Risk factors for development of painful bone metastases are being studied prospectively at our institution.

Electing Full Code in Hospice: Patient Characteristics and Live Discharge Rates.

It is unknown how many hospice enrollees elect to be full code and if this is associated with higher hospice live discharge rates. To measure the rates of hospice enrollees electing full code, the characteristics predicting full code status, and the association of full code status with various hospice live discharge patterns. Retrospective cohort study of electronic medical record data. A total of 25,636 decedents enrolled in two Michigan hospices between 2009 and 2014. Code status was defined as full code versus do-not-resuscitate (DNR) orders. Covariates include demographics, location (home, hospice facility, nursing home, and hospital), primary diagnosis, and length of stay. Hospice live discharge was defined as short (0-14 days), medium (15-179 days), and long (>179 days). A total of 12.9% of hospice enrollees elected full code status. This was significantly (p < 0.05) predicted by male sex, younger age, nonwhite race, home setting of care, and cancer diagnosis. Those with full code status had 1.76 times the adjusted odds of hospice live discharge compared with those with DNR orders (95% confidence interval [CI] 1.44-2.16) and 2.47 times the odds of short live discharge (95% CI 1.69-3.62) with no significant difference in long live discharge. The association of full code orders with hospice live discharge was stronger for nonwhite enrollees, with a live discharge rate of 23.8% versus 11.6% for African Americans with full code versus DNR orders. Those electing full code status on admission to hospice are at high risk of live hospice discharge after short enrollments, particularly nonwhite enrollees.

Disparities in location of death of adolescents and young adults with cancer: A longitudinal, population study in California.

Patients with a terminal illness should have access to their chosen location of death. Cancer is the leading cause of non-accidental death among adolescents and young adults (AYAs; those aged 15-39 years). Although surveys have suggested that a majority of these patients prefer a home death, to the authors' knowledge, little is known regarding their barriers to accessing their preferred location of death. As a first step, the authors sought to determine, across a large population, 20-year trends in the location of death among AYA patients with cancer. Using the Vital Statistics Death Certificate Database of the California Office of Statewide Health Planning and Development, the authors performed a retrospective, population-based analysis of California patients with cancer aged 15 to 39 years who died between 1989 and 2011. Sociodemographic and clinical factors associated with hospital death were examined using multivariable logistic regression. Of 30,573 AYA oncology decedents, 57% died in a hospital, 33% died at home, and 10% died in other locations (eg, hospice facility or nursing facility). Between 1989 and 1994, hospital death rates decreased from 68.3% to 53.6% and at-home death rates increased from 16.8% to 35.5%. Between 1995 and 2011, these rates were stable. Those individuals who were more likely to die in a hospital were those aged <30 years, of minority race, of Hispanic ethnicity, who lived ≤10 miles from a specialty center, and who had a diagnosis of leukemia or lymphoma. Overall, the majority of AYA cancer deaths occurred in a hospital, with a 5-year shift to more in-home deaths that abated after 1995. In-hospital deaths were more common among younger patients, patients of minority race/ethnicities, and those with a leukemia or lymphoma diagnosis. Further study is needed to determine whether these rates and disparities are consistent with patient preferences. Cancer 2017;123:4178-4184. © 2017 American Cancer Society.

Attitudes Toward Advance Directives Among Patients and Their Family Members in China

ObjectivesChinese people are generally unfamiliar with the concept of advance care planning or advance directives (ACP/ADs), which raises dilemmas in life-support choice and can even affect clinical decision making. To understand and address the issues involved better, we investigated the awareness of ACP/ADs in China, as well as people's attitudes toward medical autonomy and end-of-life care. DesignA multicenter cross-sectional survey, conducted from August 1 to December 31, 2016. SettingTwenty-five hospitals located in 15 different provinces throughout mainland China. ParticipantsPairs of adult patients without dementia or malignancies, and a family member. MeasurementsParticipants self-filled anonymous questionnaires, and the data collected were analyzed to relate patients' sociodemographic characteristics to their awareness of ACP/ADs and attitudes to health care autonomy and end-of-life care. ResultsAmong 1084 patients who completed the questionnaire, 415 (38.3%) had heard about ACP/ADs. Having been informed about ACP/ADs, 995 (91.8%) were willing to find out their true health status and decide for themselves; 549 (50.6%) wanted to institute ACP/ADs. Regarding end-of-life care, 473 (43.6%) chose Do Not Resuscitate, and 435 (40.1%) wished to forgo life-support treatment if irreversibly moribund. Patients predominantly (481, 44.4%) chose general hospital as their preferred place to spend their last days of life; only 114 (10.5%) favored a special hospice facility. Patients' main concerns during end-of-life care were symptom control (35.1%), followed by functional maintenance and quality of life (29.8%), and prolonging life (18.9%). More highly educated patients had significantly greater awareness of ACP/ADs than less well educated ones (χ2 = 59.22, P < .001) and were more willing to find out the truth for themselves (χ2 = 58.30, P ≤ .001) and make medical decisions in advance (χ2 = 55.92, P < .001). Younger patients were also more willing than older ones to know the truth (χ2 = 38.23, P = .001) and make medical decisions in advance (χ2 = 18.42, P = .018), and were also more likely to wish to die at home (χ2 = 96.25, P < .001). Only 212 patients’ family members (19.6%) wanted life-support treatment for themselves if irreversibly moribund, whereas 592 (54.6%) would want their relative to receive such procedures in the same circumstances; a similar discrepancy was evident for end-of-life invasive treatment (18.3% vs 42.7%). ConclusionsAwareness about ACP/ADs in China is still low. Providing culturally sensitive knowledge, education, and communication regarding ACP/ADs is a feasible first step to promoting this sociomedical practice.

Aesthetic Abstracts and Citations

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Translating Research to Practice: Providing Critically Ill Children the Opportunity to Go Home or to Hospice for End-of-Life Care.

A freestanding quaternary pediatric hospital in New England has been facilitating parents' requests to take their child home or to a hospice facility from an Intensive Care Unit at end of life for the withdrawal of life sustaining measures for the past 16 years. However, knowledge of the aftermath of this decision was very limited. Before responding to a growing interest in making this service more available, an exploratory study was done to learn about the parents' perceptions of the experience over time. We learned that the parents were very positive and highly recommending that pediatric palliative transports be made more available. The aim of this study was to describe the steps and rationale used to create a structured platform for pediatric palliative transports, drawing on findings from a previous study. To standardize the process, describe distinct responsibilities, and ensure quality and safety, an algorithm was created. The development of a checklist followed to enable the coordinator to follow the status of preparation for the transport. Empowered by parents' requests and positive reflections, these transports are now offered more frequently to parents of children requiring care in an intensive care unit at end of life.

Interventions for Test Anxiety in Undergraduate Nursing Students: An Integrative Review.

An integrative review was conducted to identify and evaluate interventions for test anxiety (TA) in undergraduate nursing students. Test performance has a major impact on the academic success of nursing students. Therefore, testing is a source of stress and anxiety, which may impair academic performance. A systematic search was conducted to locate peer-reviewed literature about interventions for TA in undergraduate nursing students. Review of 33 publications dated 1973 to 2014 identified 19 interventions for TA in undergraduate nursing students. Findings included experimental evidence supporting aromatherapy, music therapy, and various cognitive or behavioral interventions. Nonexperimental evidence supporting collaborative testing, crib sheets, and humorous exam items was also found. Many interventions for mitigating TA in nursing students have been evaluated since the 1970s. Current research is needed to corroborate and strengthen the evidentiary support for existing interventions and to evaluate new interventions.

Outcome of Head and Neck Cancer Patients Who Did Not Receive Curative-Intent Treatment

There exists a subgroup of patients with head and neck cancer (HNC) who neither warrant nor request curative-intent treatment and who progress to a terminal-care paradigm. The purpose of this study was to determine the frequency of and reasons for an HNC terminal-care referral and the time to and place of death for such patients. The authors undertook a retrospective cohort study of all attendees with HNC who had undergone multidisciplinary team (MDT) assessment at the Calvary Mater Hospital (Newcastle, Australia) from January 2013 through December 2014. The primary predictor variables were a heterogeneous set of factors grouped together into logical demographic (age and gender) and clinicopathologic (tumorhistology, site, and stage) categories and the reason for referral to terminal care. The secondary outcome variables were survival and place of death. A descriptive statistical analysis was undertaken and survival data were graphically displayed as Kaplan-Meier estimates. Of the 412 attendees with HNC who underwent MDT assessment, 74 (18%) were identified as having been immediately referred for terminal care. Their median survival was 6months (95% confidence interval, 4.75-7.50). The most common reason for referral for terminal care was tumor extent. The most common place of death recorded for the group was a hospice facility. This study serves as a timely reminder that when curative-intent HNC treatment optionshave been exhausted, dialog and action need to be directed to transitioning the patient to a terminal-care management paradigm.

Using the POLST Paradigm to Honor Patient Wishes Across the Care Continuum: Presenting a Comprehensive Toolkit Designed to Help Health Care Professionals and Facilities Implement the POLST Paradigm (FR431)

•Review advance care planning and define the differences between advance directives and the POLST Paradigm.•Identify challenges to POLST Paradigm implementation in nursing home, hospice, primary care offices and hospitals.•Illustrate appropriate clinician training, public education, policies and procedures in nursing homes, hospice and primary care offices to ensure patient POLST Paradigm orders are elicited, known and honored. A key recommendation from the Institute of Medicine’s (IOM) Report Dying in America is to “encourage states to develop and implement a Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in accordance with nationally standardized core requirements.” The National POLST Paradigm sets those core requirements and works to ensure that individuals with serious advanced illness or frailty not only have access to POLST Paradigm forms but to professionals who understand the value of POLST and are trained to have meaningful goals of care conversations to elicit and document patient treatment wishes properly on a POLST Paradigm form, as well as professionals who will honor them. Since its inception in 1994, the POLST Paradigm has grown exponentially and now exists, at some level, in 49 states, creating an intense need for education and resources to help facilities and professionals appropriately use POLST Paradigm Forms. Used appropriately, these actionable medical order forms potentially avoid unwanted hospitalizations and emergency department visits and achieves the triple aim. Patients have peace of mind that their wishes are known and will be honored during a medical emergency. In this concurrent session, a toolkit created in partnership with the Pew Charitable Trusts will be presented. Using POLST to Honor Patient Wishes Across the Care Continuum will help facilities implement the Paradigm by addressing the needs of specific patient populations and professionals in primary care offices, hospitals, nursing homes and hospice facilities. In addition to educating about the benefits and value of the POLST Paradigm (including how it differs and complements advance directives as well as how it fits within advance care planning), the toolkit provides setting-specific resources for POLST Paradigm implementation to address the specific needs of implementing POLST in different types of care facilities.

Two Alternatives to Intensive Care

The overall quality of life in palliative and hospice care facilities differs greatly from that in intensive care units. For example, the use of mechanical ventilation and powerful anesthetics and sedatives in the ICU can often leave otherwise informed patients incapacitated and unable to make their own health care decisions. Thus, discussions between patients and families about treatment options can be difficult, and families and surrogates are often left to do this on their own Treatments performed in the ICU are likely to be disproportionate to their needs, adding to suffering and distrust on the part of family members. To avoid this, it is important for health care providers to assess patients early and often and to discuss the proportionality of different treatments with their families and surrogates. Additionally, providers should encourage palliative and hospice care as alternatives to the many costly and likely disproportionate interventions taken in the ICU.

The Intensive Palliative Care Unit: Changing Outcomes for Hospitalized Cancer Patients in an Academic Medical Center.

Patients with advanced cancer often require complex symptom management. At Dana-Farber/Brigham and Women's Cancer Center, the intensive palliative care unit (IPCU) admits symptomatic oncology patients with uncontrolled symptoms throughout the trajectory of illness. Patients are uniquely managed by an interdisciplinary team of clinicians who focus on symptom management and advance care planning. The purpose of our analysis was to investigate goals-of-care outcomes and healthcare utilization after admission to the IPCU. We retrospectively reviewed 74 oncology patients admitted to the IPCU in August and September, 2013. A total of 67 IPCU patients who were admitted received palliative intent treatment, whereas 7 patients received curative intent care. All patients were engaged in a goals-of-care discussion during admission. Of the palliative intent patients, 58% were transferred to the IPCU from medical oncology and 42% were directly admitted. Forty-eight percent of the patients were diagnosed with metastatic lung, genitourinary, or gastrointestinal cancer. Eighty-seven percent of patients reported pain as the chief complaint at admission. Twenty-five patients experienced a change in code status from Full Code to do-not-resuscitate/do-not-incubate. A total of eight patients died in the IPCU, and 50% experienced a code status change. Eighty-eight percent of patients were discharged alive. Of those, 49% were discharged to home hospice, general inpatient hospice, or an inpatient hospice facility. The risk of 30-day readmission was 4%. Among advanced cancer patients, our findings suggest that an inpatient palliative care unit helps clarify goals of care, aids in appropriate hospice referrals, and decreases hospital readmissions.

A whole greater than the sum of the parts: Close collaboration between palliative care and clinical ethics.

53 Background: The disciplines of palliative care (PC) and clinical ethics (CE) share common content but also important distinctions in method, skill set, and clinical role in a given patient encounter. Particularly in cases of advance care planning, complex decision-making, and clarifying goals oncology teams may be challenged to know which consultation service to involve. Methods: Case report and commentary. Results: A 60 year-old man with a 3-year history of glioblastoma multiforme presented with sudden onset right-sided weakness and altered mental status. In the emergency department, a computed tomography (CT) scan demonstrated a left-sided intracranial bleed with concomitant cerebral edema and left-to-right midline shift. The patient was admitted to a surgical intensive care unit (SICU) where neurosurgery declined to operate. Within hours of admission, while the patient’s son (also his durable healthcare power-of-attorney) was considering a do-not-resuscitate order, local police arrived at the hospital, having received a 911 call from the patient’s daughter who claimed her brother and medical providers were attempting to murder her father by shifting to comfort care. The SICU team urgently consulted PC and CE. Within an hour, PC and CE clinicians met with the patient’s family to review the patient’s advance directive, counsel regarding clinical management strategies and prognosis, broach comfort care, introduce hospice, and liaise with a hospice case manager. Additionally, PC collaborated with the SICU to provide best symptom management; CE worked with hospital risk management and security to ethically mitigate escalation of more reactive family members. Within 4 hours of the consults, the patient was being transferred to a local inpatient hospice facility, where he died several days later. Conclusions: As this case demonstrates, models of close collaboration between PC and CE consultative services may swiftly facilitate appropriate transitions in care for patients with advanced cancer and simultaneous de-escalation of hospital risk. Evolving models for quality supportive care should further examine such strategies.

End-of-Life Care in Patients with Metastatic Lung Cancer Harboring Epidermal Growth Factor Receptor Mutations

Patients with metastatic nonsmall cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR) mutations benefit from improved survival and quality of life with EGFR-directed therapy. We sought to explore if these improvements in cancer care impacted the delivery of end-of-life (EOL) care in this population. We retrospectively reviewed medical records of patients cared for at our institution with the diagnosis of metastatic EGFR-mutant NSCLC who died by January 2015. Sixty-one patients were included. The majority of patients were female (68%), white or Asian (97%), and never or minimal smokers (76%). Forty-two out of fifty-eight patients (72%) received chemotherapy within 30 days of death. Forty-one out of sixty-one patients (67%) had a hospital admission within 30 days of death. EOL outcomes were known for 53 patients. Of these, 34 (64%) patients enrolled on hospice. The median length of stay on hospice was 6 days (range 0-206). Thirty-three (62%) patients died at home with hospice services or at an inpatient hospice facility. Eighteen patients (34%) died in the hospital. Patients with metastatic NSCLC harboring EGFR mutations had high rates of chemotherapy use and hospital admissions in the last month of life, and many died in the hospital. Hospital admissions near the EOL and short admissions to hospice are indicators of poor quality EOL care and are likely a result of prolonged chemotherapy administration in this population. Thus, current healthcare delivery models may be insufficient to provide comprehensive EOL care for patients with EGFR mutations.

Nationwide survey on volunteers' training in hospice and palliative care in Poland

BackgroundVolunteers working in hospice and palliative care facilities in Poland undertake various activities which are performed in accordance with legal regulations and the individual policies of each hospice. The aim...

A Longitudinal Analysis of Site of Death: The Effects of Continuous Enrollment in Medicare Advantage Versus Conventional Medicare

This study assessed the odds of dying in hospital associated with enrollment in Medicare Advantage (M-A) versus conventional Medicare Fee-for-Service (M-FFS). Data were derived from the 2008 and 2010 waves of the Health and Retirement Study ( n = 1,030). The sample consisted of elderly Medicare beneficiaries who died in 2008-2010 (34% died in hospital, and 66% died at home, in long-term senior care, a hospice facility, or other setting). Logistic regression estimated the odds of dying in hospital for those continuously enrolled in M-A from 2008 until death compared to those continuously enrolled in M-FFS and those switching between the two plans. Results indicate that decedents continuously enrolled in M-A had 43% lower odds of dying in hospital compared to those continuously enrolled in M-FFS. Financial incentives in M-A contracts may reduce the odds of dying in hospital.

Real-world treatment practice in patients with advanced melanoma in the era before ipilimumab: results from the IMAGE study.

The therapeutic landscape for advanced melanoma has recently been transformed by several novel agents (immune checkpoint inhibitors and molecular‐targeted agents). The prospective, multi‐site, observational study IMAGE (ipilimumab: management of advanced melanoma in real practice) included a retrospective cohort to describe real‐world treatment prior to approval of the immune checkpoint inhibitor ipilimumab. This retrospective cohort of patients, who started second‐line/subsequent treatment (index therapy) for advanced melanoma within 3 years before ipilimumab approval, was selected randomly by chart review. Collected data included treatment history, patient outcomes, and healthcare resource utilization. All patients had ≥1 year of follow‐up data. This analysis included 177 patients from Europe (69%) and North America (31%). The most common index therapies (used alone or in combination) were fotemustine (23%), dacarbazine (21%), temozolomide (14%), and platinum‐based chemotherapy (14%). Most patients (89%) discontinued index treatment during the study period; the most common reason was disease progression (59%). Among patients with tumor assessment (153/177; 86%), 2% had complete response, 5% had partial response, and 12% had stable disease on last tumor assessment. At 1‐year study follow‐up, median progression‐free survival was 2.6 months (95% confidence interval [CI], 2.1–2.9) and median overall survival was 8.8 months (95% CI, 6.5–9.7). During follow‐up, 95% of the patients had healthcare visits for advanced melanoma, 74% of whom were hospitalized or admitted to a hospice facility. These results provide insights into patient care with advanced melanoma in the era before ipilimumab and may serve as a benchmark for new agents in future real‐world studies.

A pragmatic approach for measuring and monitoring hospitalizations in patients receiving chemotherapy for pancreatic cancer.

278 Background: Hospitalizations in patients receiving chemotherapy are common and costly. In order to test interventions to reduce hospitalizations in chemotherapy patients, efficient approaches are needed for monitoring the incidence of hospitalization. Methods: We evaluated the monthly frequency of hospitalization in patients receiving active chemotherapy for pancreas cancer. Two definitions were used to identify patients under “active” chemotherapy treatment in a given month; both definitions required that patients were alive on the first day of the evaluation month. For definition A, patients were defined as active if they received any chemotherapy treatment in the evaluation month or the preceding calendar month. Definition B included any chemotherapy during the evaluation month or the two prior months. Reporting functions of the electronic health record (EHR, Epic Systems) were used to generate reports of chemotherapy treatment history and hospital discharges. Data were then combined using statistical software (SAS). Outcomes included the number of active chemotherapy patients per month, the number of hospital discharges per 100 chemotherapy patients, and discharge disposition by hospitalization. Results: There were an average of 101 active chemotherapy patients and 11 hospitalizations per month, using definition A to identify active chemotherapy patients. Corresponding figures using definition B were 115 active patients and 13 hospitalizations per month. The mean number of hospital discharges per month per 100 patients was 10.5 (SD 3.9) vs. 10.9 (4.4). Hospital discharge dispositions (using the inclusive definition B population) included home (49%), home w/ services (19%), home hospice (14%), hospice facility (11%), and SNF (8%). Conclusions: EHRs permit efficient approaches for monitoring monthly hospitalization frequency across a population of active chemotherapy patients. The observed frequency of hospitalization was similar with both active patient definitions. Capability to monitor hospitalization frequencies in active chemotherapy patients will facilitate development of quality improvement programs to reduce hospitalizations.

Length of hospital stay after hip fracture and risk of early mortality after discharge in New York state: retrospective cohort study

Study question Can the length of hospital stay for hip fracture affect a patient’s risk of death 30 days after discharge?Methods In a retrospective cohort study, population based registry data...

Hospice care in the Netherlands: who applies and who is admitted to inpatient care?

BackgroundTen percent of non-sudden deaths in the Netherlands occur in inpatient hospice facilities. To investigate differences between patients who are admitted to inpatient hospice care or not following application, how diagnoses compare to the national population, characteristics of application, and associations with being admitted to inpatient hospice care or not.MethodsData from a database representing over 25 % of inpatient hospice facilities in the Netherlands were analysed. The study period spanned the years 2007–2012. Multivariate regression analyses were performed to study associations between demographic and application characteristics, and admittance.ResultsTen thousand two hundred fifty-four patients were included. 84.1 % of patients applying for inpatient hospice care had cancer compared to 37.0 % of deaths nationally. 52.4 % of applicants resided in hospital at the time of admission. Most frequent reasons for application were the wish to die in an inpatient hospice facility (70.5 %), needing intensive care or support (52.2 %), relieving caregivers (41.4 %) and needing pain/symptom control (39.9 %). Living alone (OR 1.68, 95 % CI 1.46–1.94), having cancer (OR 1.40, 95 % CI 1.11–1.76), relieving caregivers (OR 1.18, 95 % CI 1.01–1.38), needing pain/symptom control (OR1.72, 95 % CI 1.46–2.03) wanting inpatient hospice care until death (vs respite care) (OR 3.59, 95 % CI 2.11–6.10), wanting to be admitted as soon as possible (OR 1.64, 95 % CI 1.42–1.88), and being referred by a primary care professional (OR 1.36, 95 % CI 1.17–1.59) were positively associated with being admitted. Wishing to die in an inpatient hospice facility was negatively associated with being admitted (OR 0.85, 95 % CI 0.72–1.00).ConclusionsThis study suggests that when applying for inpatient hospice care, patients who seem most urgently in need of inpatient hospice care are more frequently admitted. However, non-cancer patients seem to be an under-represented population. Staff should consider application based on need for palliation, irrespective of diagnosis.