Life-prolonging Treatment Research Articles

The Influence of Hypothetical Death Scenarios on Multidimensional End-of-Life Care Preferences.

Differences in end-of-life (EOL) care preferences (eg, location of death, use of life-sustaining treatments, openness to hastening death, etc) based on hypothetical death scenarios and associated physical and/or cognitive losses have yet to be investigated within the palliative care literature. The purpose of this study was to explore the multidimensional EOL care preferences in relation to 3 different hypothetical death scenarios: pancreatic cancer (acute death), Alzheimer disease (gradual death), and congestive heart failure (intermittent death). General linear mixed-effects regression models estimated whether multidimensional EOL preferences differed under each of the hypothetical death scenarios; all models controlled for personal experience and familiarity with the disease, presence of an advance directive, religiosity, health-related quality of life, and relevant demographic characteristics. A national sample of healthy adults aged 50 years and older (N = 517) completed electronic surveys detailing their multidimensional preferences for EOL care for each hypothetical death scenario. The average age of the participants was 60.1 years (standard deviation = 7.6), 74.7% were female, and 66.1% had a college or postgraduate degree. Results revealed significant differences in multidimensional care preferences between hypothetical death scenarios related to preferences for location of death (ie, home vs medical facility) and preferences for life-prolonging treatment options. Significant covariates of participants' multidimensional EOL care preferences included age, sex, health-related quality of life, and religiosity. Our hypothesis that multidimensional EOL care preferences would differ based on hypothetical death scenarios was partially supported and suggests the need for disease-specific EOL care discussions.

Improving Hospice Referral: Application of Regret-Based Decision Modeling at End-of-Life Care

Introduction: Terminally ill patients are often faced with the decision to forgo potentially life-prolonging treatment or to accept hospice care leading to a peaceful death. The decision process in such situations is heavily affected by emotions, chief among them is regret. Modern cognitive science increasingly accepts a dual processing approach to human cognition which takes into account both emotion-based (type 1) and analytical-based (type 2) cognitive processing. Because regret is a human emotion (type 1), which involves counterfactual deliberations (type 2), we have previously proposed that it can activate both cognitive domains by serving as a link between type 1 and type 2 processes and therefore help with end of life decisions more precisely than other decision making methodologies. Here, we report the application of a regret-based model built to facilitate referral to hospice while helping patients clarify their preferences related to how they wish to spend the remaining days of their lives.Methods: Between March 2013 to December 2015, we conducted a prospective cohort study at the Tampa General Hospital and the Moffitt Cancer Center that enrolled 178 consecutive adult patients aware of the terminal nature of their disease. Eligible patients were those who were at the point in their care where they had to decide between continuing potentially "curative/life-prolonging" treatment (Rx) or accepting hospice care. The study was broken down into 4 steps. First, we computed the patient's probability of survival at 6 months using a validated Palliative Performance Score (PPS-based) predictive model. This probability was communicated to patients as i. percentage, ii. pictorial, and iii. life expectancy in days. Then, we used the Dual Visual Analog Scale technique (DVAS) to elicit patient preferences towards continuing current treatment vs. accepting hospice care. The first scale in DVAS measured the levels of regret of omission (RGO) (e.g. failure to reap hospice benefits and incurring treatment harms) while the second scale measured regret of commission (RGC) (e.g. incurring harms from hospice and failing to provide potential benefits of treatment). The ratio RGO/RGC was used to compute the threshold probability at which a patient is indifferent between accepting hospice care or continuing current treatment. Each patient's threshold was contrasted against the previously estimated survival probability to suggest a patient specific management plan, which was later compared with the patient's actual choice. The final step of the study involved asking each patient a series of qualitative questions to evaluate the usefulness of the regret model in the hospice referral process.Results: 96% (171/178) of the patients found the information provided by the model helpful; 90% (160/178) stated that it will influence their care decision. 85% (151/178) of the patients agreed with the model’s recommendations to either accept hospice care or continue with current treatment [p<0.000001]. The regret model predicted the actual choices for 72% (128/178) of patients [p <0.00001]. Logistic regression analysis showed that people who were initially inclined to be referred to hospice and were predicted to choose hospice over disease-directed treatment by the regret model had close to 98% probability of choosing hospice care at the end of their lives. No other factors (age, gender, race, educational status and pain level) affected the patient actual choice.Conclusions: To our knowledge, this is the first formal study in which helping patient clarify their preferences enabled them to make actual choices with high level of satisfaction. The regret model was well received by patients and its recommendations were largely accepted. We found that people suffering from a terminal disease who are initially inclined to choose hospice and do not regret such a choice will select hospice care with high level of certainty. We conclude that using the regret model to elicit patient choices is both descriptively and prescriptively valid and can be easily implemented in the actual practice. DisclosuresNo relevant conflicts of interest to declare.

Preserving dignity in end-of-life nursing home care: Some ethical challenges

A central task in palliative care is meeting the needs of frail, dying patients in nursing homes. The aim of this study was to investigate how healthcare workers are influenced by and deal with ethical challenges in end-of-life care in nursing homes. The study was inspired by clinical application research. Researchers and clinical staff, as co-researchers, collaborated to shed light on clinical situations and create a basis for new practice. The analysis resulted in the main theme, ‘Dignity in end-of-life nursing home care’, and the sub-categories ‘Challenges regarding life-prolonging treatment’ and ‘Uncertainty regarding clarification conversations’. Our findings indicate that nursing homes do not provide necessary organizational frames for the team approach that characterizes good palliation, and therefore struggle to give dignified care. Ethical challenges experienced by healthcare workers are closely connected to inadequate organizational frames.

1307P - Use of treatments of questionable benefit in hospitalized patients with metastatic gastric or esophageal cancer near the end of life. A country-wide, register-based study

The benefit of life-prolonging treatments in terminally ill cancer patients is debated. Little is know, however, about the aggressiveness of care in patients with metastatic esophagus or stomach cancer. Register-based study in France, including all hospitalized adults (≥20 years) who died as the result of metastatic esophageal or gastric cancer between 2010 and 2013. The receipt of chemotherapy and the use of artificial nutrition during the last 3 months of life were defined as primary outcomes. 4,031 patients with metastatic esophageal cancer and 10,423 patients with metastatic gastric cancer were included (n total= 14,454). Overall, 47.6% of patients received chemotherapy in their last 3 months of life, with a significant decrease over time (from 35.9% during the third month before death to 7.9% in the final week of life). In contrast, the receipt of artificial nutrition rose from 9.4% to 16% over the same period of time. This increase in the use of artificial nutrition was observed for both esophagus and stomach cancer, across all age-groups, and regardless of the number of chronic comorbidities (p > 0.001 for trend). During the last week before death, the likelihood of receiving artificial nutrition decreased with age (adjusted OR= 0.80, 95%CI= 0.77-0.84 for each 10-year increase in age), and was significantly higher for patients with esophageal cancer compared with gastric cancer (adjusted OR= 1.25, 95%CI= 1.13-1.37). In addition, 3.5% of patients received invasive ventilation during the last month before death (5% of patients with esophageal cancer and 3% of patients with gastric cancer, p < 0.001). 6% of patients eventually died in Intensive Care Units, and only 12.6% died in Palliative Care Units. Our study shows that hospitalized patients with metastatic esophageal or gastric cancer are likely to receive treatments of questionable benefit near the end of life. Interventional studies focusing on patient reported outcomes are needed to assess the clinical benefit of artificial nutrition for patients with terminal cancer.

Causes and consequences of delays in treatment-withdrawal from PVS patients: a case study of Cumbria NHS Clinical Commissioning Group v Miss S and Ors [2016] EWCOP 32

Life-extending treatment, in the form of artificial nutrition and hydration, is often provided to people in permanent vegetative states (PVS) in England and Wales for many years, even when their...

Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee.

The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units) provides examples of potentially inappropriate treatments; however, no clear definition is provided. This statement was developed to provide a clear definition of inappropriate interventions in the ICU environment. A subcommittee of the Society of Critical Care Medicine Ethics Committee performed a systematic review of empirical research published in peer-reviewed journals as well as professional organization position statements to generate recommendations. Recommendations approved by consensus of the full Society of Critical Care Medicine Ethics Committees and the Society of Critical Care Medicine Council were included in the statement. ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient's neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. This definition should not be considered exhaustive; there will be cases in which life-prolonging interventions may reasonably be considered inappropriate even when the patient would survive outside the acute care setting with sufficient cognitive ability to perceive the benefits of treatment. When patients or surrogate decision makers demand interventions that the clinician believes are potentially inappropriate, the seven-step process presented in the multiorganization statement should be followed. Clinicians should recognize the limits of prognostication when evaluating potential neurologic outcome and terminal cases. At times, it may be appropriate to provide time-limited ICU interventions to patients if doing so furthers the patient's reasonable goals of care. If the patient is experiencing pain or suffering, treatment to relieve pain and suffering is always appropriate. The Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement. This statement provides added guidance to clinicians in the ICU environment.

Liturgy for Last Days: Pastoral Reflections on Acknowledging and Supporting the End-of-Life Experience

In the face of advancing medical technology, there are choices to make about undertaking or terminating life-prolonging treatments. The legalization of physician-prescribed lethal medication for terminally ill patients in some states has fostered increased discussion about end-of-life issues. This article includes several stories from the author's pastoral experience along with suggestions and prayers to help patients and their loved ones address this significant life passage in the context of their faith.

The safety and efficacy of radium-223 dichloride for the treatment of advanced prostate cancer

ABSTRACTIntroduction: A number of drugs have been shown to extend life expectancy in castration-resistant prostate cancer (CRPC). Skeletal related events (SREs) secondary to bone metastases cause significant morbidity for men with CRPC. The α-emitting radiopharmaceutical radium-223 dichloride has been shown to improve overall survival, time to symptomatic skeletal events (SSEs) and quality of life in CRPC.Areas covered: The development of radium-223 from pre-clinical studies to the evidence of efficacy and safety from a phase 3 trial is discussed as well as its pharmacokinetics and metabolism. The integration of radium-223 into routine care for patients with advanced prostate cancer is included including a comparison with other agents in this setting.Expert commentary: The risk/benefit ratio for radium-223 is very similar to that of other agents used in the CRPC setting and is a treatment option for men unsuitable for cytotoxic chemotherapy because of comorbidities. The ALSYMPCA trial demonstrated an improvement in SSEs with radium-223. This is a clinically relevant end-point as not all radiologically-detected SREs are apparent to patients. The correct sequencing of the life-prolonging treatments available to men with CRPC is subject to debate. Radium-223 therapy should be considered before the development of visceral metastases. Drug-combination studies are underway.

Pulmonary Fibrosis in Hermansky-Pudlak Syndrome.

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive genetic disorder characterized by oculocutaneous albinism and a bleeding diathesis due to platelet dysfunction. More than 50% of cases worldwide are diagnosed on the Caribbean island of Puerto Rico. Genetic testing plays a growing role in diagnosis; however, not all patients with HPS have identified genetic mutations. In Puerto Rico, patients with HPS are often identified shortly after birth by their albinism, although the degree of hypopigmentation is highly variable. Ten subtypes have been described. Patients with HPS-1, HPS-2, and HPS-4 tend to develop pulmonary fibrosis in Puerto Rico; 100% of patients with HPS-1 develop HPS-PF. HPS-PF and idiopathic pulmonary fibrosis are considered similar entities (albeit with distinct causes) because both can show similar histological disease patterns. However, in contrast to idiopathic pulmonary fibrosis, HPS-PF manifests much earlier, often at 30-40 years of age. The progression of HPS-PF is characterized by the development of dyspnea and increasingly debilitating hypoxemia. No therapeutic interventions are currently approved by the U.S. Food and Drug Administration for the treatment of HPS and HPS-PF. However, the approval of two new antifibrotic drugs, pirfenidone and nintedanib, has prompted new interest in identifying drugs capable of reversing or halting the progression of HPS-PF. Thus, lung transplantation remains the only potentially life-prolonging treatment. At present, two clinical trials are recruiting patients with HPS-PF to identify biomarkers for disease progression. Advances in the diagnosis and management of these patients will require the establishment of multidisciplinary centers of excellence staffed by experts in this disease.

Abstract 3971: Non-invasive assessment of prostate-specific membrane antigen (PSMA) expression as a prognostic marker in men with metastatic castration-resistant prostate cancer (mCRPC)

Abstract Background: PSMA is nearly universally expressed by PC, has a correlation with androgen receptor (AR) pathway dysregulation, and some studies have pointed towards PSMA expression as a prognostic marker. Non-invasive measurement of PSMA expression may be biomarker of AR activity in animal models.[Evans et al, PNAS 2011] Anti-PSMA monoclonal antibody J591 has been utilized both for imaging as well as therapeutics and we have published semi-quantitative scoring in the setting of therapeutic clinical trials. Methods: Patients with mCRPC underwent planar gamma camera imaging following radiolabeled (RL) J591 injection (177Lu- or 111In-J591). RL-J591 images were semi-quantitatively scored using a 5-point visual score (VS) system [Tagawa et al, Clin Cancer Res 2013]. Overall survival (OS) was calculated from the date of imaging to death or last follow up. As several life-prolonging treatments (docetaxel, sipuleucel-T, cabazitaxel, abiraterone (Abi), enzalutamide (Enza), radium-223) became available during the study time period, treatment following RL-J591 imaging was recorded and used in multivariate analysis. Results: Between 2000 and 2015, 165 patients with mCRPC were imaged following RL-J591 and semi-quantitatively scored for PSMA expression by VS. Baseline demographics included median age of 71.3 years (44.5-85.9); bone metastases present in 86.7%, 52.7% with LN mets, 17% with lung mets, 7.9% with liver mets, 1.8% other mets. Fifty three (32.2%) had low PSMA expression by imaging (VS 0-1) and 112 (67.8%) had high PSMA expression (VS 2-5). Post RL-J591 imaging, 41.2% (68/165) patients received life prolonging therapy, including taxane chemotherapy (33.9%), Abi/Enza (14.5%), sipuleucel-T (1.2%), or radium-223 (1.2%). At last follow up 12.7% (21/165) patients were alive. Median OS was 22.6 months in patients with low PSMA expression and 16.6 mo with high PSMA expression (P = 0.07). Those with subsequent receipt of life prolonging therapy had OS of 23.6 months vs 14.3 mo (P = 0.002). On multivariable analysis controlling for life prolonging therapy, higher PSMA expression by imaging was a significant predictor for poorer OS (adjusted hazard ratio = 1.60; 95% CI = 1.10, 2.31; P = 0.01). Conclusion: Non-invasive measurement of PSMA expression may be evaluated on a semi-quantitative basis via planar imaging. The level of PSMA expression is inversely associated with survival when controlling for receipt of known life-prolonging therapy. With the introduction of newer quantitative molecular imaging (i.e. PET), quantitative PSMA imaging may prove to be a useful prognostic tool. Citation Format: Kavya Pinto-Chengot, Yuliya Jhanwar, Jaspreet Batra, Beerinder Karir, Shankar Vallabhajosula, Paul Christos, Ana Molina, Himisha Beltran, David M. Nanus, Stanley J. Goldsmith, Neil H. Bander, Scott T. Tagawa. Non-invasive assessment of prostate-specific membrane antigen (PSMA) expression as a prognostic marker in men with metastatic castration-resistant prostate cancer (mCRPC). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3971.

Discordant expectations about prognosis in critically ill patients

Nearly half of all adults in the United States are unable to make medical decisions for themselves about whether to accept life-prolonging interventions near the end of their life (1). Individuals who make medical decisions for critically ill patients unable to make decisions for themselves, termed surrogates, commonly have misperceptions about the prognoses of the patients they are serving as surrogates for. Such misperceptions have been reported to be attributed to poor comprehension or misunderstandings of medical information by patient surrogates and/or inadequate communication between surrogates and physicians (2,3).

Patterns of metastatic disease progression after treatment with first-line enzalutamide or abiraterone in castration-resistant prostate cancer (CRPC).

e16539Background: Abiraterone (A) and enzalutamide (E) are life-prolonging treatments for metastatic CRPC, yet their potent activity against the androgen receptor (AR) axis often yields tumors that...

Association of Palliative Care Consultation With Reducing Inpatient Chemotherapy Use in Elderly Patients With Cancer in Japan: Analysis Using a Nationwide Administrative Database.

The administration of chemotherapy at the end of life is considered an aggressive life-prolonging treatment. The use of unnecessarily aggressive therapy in elderly patients at the end of life is an important health-care concern. To explore the impact of palliative care consultation (PCC) on chemotherapy use in geriatric oncology inpatients in Japan by analyzing data from a national database. We conducted a multicenter cohort study of patients aged ≥65 years, registered in the Japan National Administrative Healthcare Database, who died with advanced (stage ≥3) lung, stomach, colorectal, liver, or breast cancer while hospitalized between April 2010 and March 2013. The relationship between PCC and chemotherapy use in the last 2 weeks of life was analyzed using χ2 and logistic regression analyses. We included 26 012 patients in this analysis. The mean age was 75.74 ± 6.40 years, 68.1% were men, 81.8% had recurrent cancer, 29.5% had lung cancer, and 29.5% had stomach cancer. Of these, 3134 (12%) received PCC. Among individuals who received PCC, chemotherapy was administered to 46 patients (1.5%) and was not administered to 3088 patients (98.5%). Among those not receiving PCC, chemotherapy was administered to 909 patients (4%) and was not administered to the remaining 21 978 patients (96%; odds ratio [OR], 0.35; 95% confidence interval, 0.26-0.48). The OR of chemotherapy use was higher in men, young-old, and patients with primary cancer. Palliative care consultation was associated with less chemotherapy use in elderly Japanese patients with cancer who died in the hospital setting.

Ageing, justice and resource allocation

Around the world, the population is ageing in ways that pose new challenges for healthcare providers. To date these have mostly been formulated in terms of challenges created by increasing...

Abstracts from Center to Advance Palliative Care National Seminar Palliative Care Everywhere: Bridging the Gaps November 12-14, 2015 San Antonio, TX.

Abstracts from Center to Advance Palliative Care National Seminar Palliative Care Everywhere: Bridging the Gaps November 12-14, 2015 San Antonio, TX.

Radiotherapy cannot prolong overall survival of young prostate cancer patients with bone metastases.

BackgroundPatients with prostate cancer is commonly diagnosed with bone metastases. With the growing use of prostate-specific antigen testing, the frequency of prostate cancer has progressively increased in patients younger than 70 years. Radiotherapy is recognized for its effect on local control of bone metastases, but whether it could prolong overall survival is still controversial.MethodsA total of 113 prostate cancer patients (<70y) with bone metastases were retrospectively analyzed. The Kaplan–Meier method was used for survival analysis with log-rank test. Multivariate analysis was performed to find the prognostic factors with the COX regression model.ResultsThe 1-, 2-, 3-, 5-, 7- and 10-year survival rates were 97.14, 82.86, 62.61, 38.76, 25.83 and 13.84 % respectively in the radiotherapy group, and 92.75, 73.91, 54.66, 36.63, 26.03 and 17.85 % respectively in the non-radiotherapy group, which showed no significant difference. Multivariate COX regression showed the overall survival was associated with alkaline phosphatase when bone metastases occurred and the number of bone metastases.ConclusionWith the advances in life-prolonging treatment of metastatic prostate cancer, radiotherapy may not be the first choice for young bone metastatic prostate cancer patients in order to improve survival.

Criminal Law Dilemmas in Withholding and Withdrawal of Intensive Care

Regarding the question under which conditions a physician in Slovenia is allowed to omit life-prolonging medical treatment of dying patients, the main legal source is the Patient Rights Act, adopted in Slovenia in 2008 (parallel to Criminal Code of Slovenia). Under this law, there are two possible circumstances in deciding about life-prolonging medical treatment regarding dying patients: a) on the basis of the so-called patient’s testament in the sense of Art. 34 of the Patient Rights Act; and b) without any known patient's testament in the sense of Art. 34 of the Patient Rights Act. Such decisions can also be contrary to a decisive wish of relatives of the dying patient to prolong the patient’s life under all circumstances. If this decision is reached with full respect of the Patient Rights Act as well as the rules of medical science, omitting life prolonging medical treatment cannot be unlawful in the sense of medical criminal law.

Discussing end-of-life issues in nursing homes: a nationwide study in France.

discussing end-of-life issues with nursing home residents and their relatives is needed to ensure patient-centred care near the end of life. this study aimed to estimate the frequency of nursing home physicians discussing end-of-life issues with residents and their relatives and to investigate how discussing end-of-life issues was associated with care outcomes in the last month of life. post-mortem cohort study in a nationwide, representative sample of 78 nursing home facilities in France. Residents who died from non-sudden causes between 1 October 2013 and 31 May 2014 in these facilities were included (n = 674). end-of-life issues were discussed with at most 21.7% of the residents who died during the study period. In one-third of the situations (32.8%), no discussion about end-of-life-related topics ever occurred, either with the resident or with the relatives. Older people with severe dementia were less likely to have discussed more than three of the six end-of-life topics we investigated, compared with residents without dementia (OR = 0.17, 95% CI = 0.08-0.22). In the last month of life, discussing more than three end-of-life issues with the residents or their relatives was significantly associated with reduced odds of dying in a hospital facility (adjusted OR = 0.51, 95% CI = 0.33-0.79) and with a higher likelihood of withdrawing potentially futile life-prolonging treatments (adjusted OR = 2.37, 95% CI = 1.72-3.29). during the last months of life, discussions about end-of-life issues occurred with only a minority of nursing home decedents, although these discussions may improve end-of-life care outcomes.

Abstract IA09: Intervening on the financial toxicity of cancer care

Abstract Evidence suggests that a considerably large proportion of cancer patients are affected by treatment-related financial harm. As medical debt grows for some with cancer, the down-stream effects can be catastrophic, with a recent study suggesting a link between extreme financial distress and worse mortality. At least three factors might explain the relationship between extreme financial distress and greater risk of mortality: 1) overall poorer well-being; 2) impaired health-related quality of life; and 3) sub-par quality of care. While research has described the financial harm associated with cancer treatment, little has been done to effectively intervene on the problem. Long-term solutions must focus on policy changes to reduce unsustainable drug prices and promote innovative insurance models. For example, the government could play a role if, for example, the Centers for Medicare and Medicaid Services was allowed to negotiate prices with drug makers, which some argue would result in lower drug prices in the United States. Another policy initiative could promote pricing based on outcome, where inadequate response to a drug would result in a refund. Payers must play a role, as well. A greater proportion of costs has been shifting to patients in the form of higher premiums, deductibles, and tiered formularies. Value-based insurance models might reduce cost-sharing for patients facing expensive but life-prolonging treatment. Realistically, any policy intervention directed at manufacturers or payers is unlikely to be implemented anytime soon. But in the meantime, patients continue to struggle with high out-of-pocket costs. For more immediate solutions, we should look to the oncologist and patient. First, to intervene today on high patient costs, oncologists should, focus on the value of care delivered. Second, oncologists must initiate the conversation. As oncologists, we need to focus more on goals of care discussions early in the treatment course. Third, if patients are prompted to broach the topic of costs, physicians must be prepared for the discussion. As such, interventions must focus on educating physicians on how to engage patients regarding value in cancer care. Fourth, to reduce financial toxicity, patients have a role to play. Patient-level interventions must focus on improving the patients cost-related health literacy. Financial toxicity is a concern for a growing proportion of patients, with half of all Medicare patients with cancer at risk of being underinsured. We now have an evidence-based list of harms that patients experience as a result of cancer treatment-related out-of-pocket costs. A recent study suggests that extreme financial distress as manifested by personal bankruptcy might be associated with worse mortality in cancer patients. That relationship between financial distress and worse outcomes is likely explained by the impact of cancer-related expenses on patient well-being, health-related quality of life, and adherence to anti-cancer therapy. Research should focus on verifying and further describing this relationship. Long-term solutions must include policy shifts involving how we set prices, negotiate prices, and insure patients. But for more immediate solutions, interventions should focus on the oncologist and patient. To reduce financial toxicity, we should intervene today. Citation Format: S. Yousuf Zafar. Intervening on the financial toxicity of cancer care. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr IA09.

End-of-life decisions for people with intellectual disability – a Swiss survey

Objectives: The aim of this study was to explore the prevalence and nature of end-of-life decisions for people with disabilities in Swiss residential homes and determine their involvement making these decisions.Methods: All of the residential homes for adults with disabilities in Switzerland (N = 437) were invited to participate in a cross-sectional survey. The survey response quote was 58.2%. Residential home directors provided information on 233 deaths. The chi-square test was used to study differences in the prevalence and nature of end-of-life decisions between people with intellectual disability (ID) and people with other disabilities. The Mann–Whitney test was used to analyze differences in their involvement in end-of-life decisions. Binary logistic regression analyses were used to analyze factors determining the prevalence of withholding life-prolonging treatment from these residents.Results: A high prevalence of end-of-life decisions was found (70.4%). For people with ID, the decision to abandon life-prolonging treatment was more often taken (46.2%, 72 of 156 residents) than for people with other disabilities (24.7%, 19 of 77 residents) (χ2(1, N = 233) = 9.992, P ≤ 0.01). The following variables were positively associated with the decision to withhold life-prolonging treatment: presence of advanced directives (odds ratio [OR] 2.998; 95% CI 1.629, 5.518), degree of disability (OR 1.677; 95% CI 1.247, 2.256) and ID (OR 2.265; 95% CI 1.064, 4.823).Conclusion: This study provides the first insight into end-of-life decision making for people with ID in Switzerland. The results have implications on surrogate decision making for people with ID living in residential homes.