Near End Of Life Research Articles

Paying for advance care planning in medicare: Impacts on care and spending near end of life

Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP)—the process of discussing and recording patient preferences for goals of care—on care utilization, spending, and mortality outcomes for critically ill Medicare patients. We find that billed ACP services substantially increase hospice use and hospice spending within a year, accompanied by corresponding increase in one-year mortality. The impacts of ACP services on hospice use and spending are especially prominent among patients with dementia and those of lower socioeconomic status. Among decedents, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. Our findings suggest that paying for ACP services can be effective in improving hospice use for critically ill Medicare patients, with the (possibly intended) consequence of increased one-year mortality.

Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study.

A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use. To characterize TLT use in patients with acute respiratory failure (ARF). Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours. Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record. Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01). In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

Effects of red blood cell transfusion on patients undergoing cardiac surgery in Queensland – a retrospective cohort study

BackgroundPacked red blood cell (pRBC) transfusion is a relatively safe and mainstay treatment commonly used in cardiac surgical patients. However, there is limited evidence on clinical effects of transfusing blood nearing end-of shelf life that has undergone biochemical changes during storage.ObjectiveTo investigate evidence of associations between morbidity/mortality and transfusion of blood near end of shelf-life (> 35 days) in cardiac surgical patients.MethodsData from the Queensland Health Admitted Patient Data Collection database 2007–2013 was retrospectively analysed. Coronary artery bypass graft and valvular repair patients were included. Multivariable logistic regression was used to examine the effect of pRBC age (< 35 days vs. ≥ 35 days) on in-hospital mortality and morbidity. As secondary analysis, outcomes associated with the number of pRBC units transfused (≤ 4 units vs. ≥ 5 units) were also assessed.ResultsA total of 4514 cardiac surgery patients received pRBC transfusion. Of these, 292 (6.5%) received pRBCs ≥ 35 days. No difference in in-hospital mortality or frequency of complications was observed. Transfusion of ≥ 5 units of pRBCs compared to the ≤ 4 units was associated with higher rates of in-hospital mortality (5.6% vs. 1.3%), acute renal failure (17.6% vs. 8%), infection (10% vs. 3.4%), and acute myocardial infarction (9.2% vs. 4.3%). Infection carried an odds ratio of 1.37 between groups (CI = 0.9–2.09; p = 0.14) and stroke/neurological complications, 1.59 (CI = 0.96–2.63; p = 0.07).ConclusionIn cardiac surgery patients, transfusion of pRBCs closer to end of shelf-life was not shown to be associated with significantly increased mortality or morbidity. Dose-dependent differences in adverse outcomes (particularly where units transfused were > 4) were supported.

Needs, Experiences, and Hopes for Aging Futures among Older Adults in the LGBTQ Communities: A Qualitative Study in Israel

Older lesbian, gay, bisexual, trans, and queer (LGBTQ) individuals tend to live alone, mostly without children and with scarce support from nuclear family members or biological kin. Moreover, traditional resources may not suit their specific end-of-life care needs. While studies have examined these topics in general, they lack focus on end-of-life needs, care, and planning in Israel. Moreover, research on this topic among members of LGBTQ communities is specifically lacking. This study, therefore, aimed at identifying and understanding the attitudes, perceptions, and meanings of older LGBTQ individuals in Israel regarding their needs and challenges, as they age and near end of life. The phenomenological qualitative research methodology was applied, following the interpretive approach. Twenty-one middle-aged and older LGBTQ individuals in Israel, aged ≥ 55, participated in the study. In-depth semi-structured interviews, conducted from November 2020 to April 2021, were audio-recorded, transcribed, and de-identified. Five themes emerged from the interviews: (1) Experiences of loneliness, marginalization, and trauma, and coping through liberation; (2) ageism and exclusion of older adults; (3) elastic and challenging relationships; (4) end of life as reverting into the closet and heteronormativity; and (5) death as a source of generativity and creativity. The study demonstrates that loneliness is an existential experience, exacerbated by the intersectionality of LGBTQ communities. In turn, chosen family members play a minimal role in the end-of-life care of their loved ones. While conveying ambivalence toward social services and housing for the aging, participants in this study expressed fear of being discriminated against and having to re-enter the closet as they age. Ageism and end of life do not represent finality and extinction, yet instead, signify hope and revival. Following Sandberg and Marshall’s (2017) concept of queering aging futures, this study refines our understanding of life courses, demonstrating that living and thriving in old age could be positive and desirable. As such, ageism and end of life do not necessarily represent finality and extinction, and may instead signify hope and revival. The unique challenges associated with family and social support of older adults who are LGBTQ members, and their implications on care, deserve further research and are important for practice.

A Hospice Transitions Program for Patients in the Emergency Department

Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

Healthcare Utilization of Pediatric Patients with Cancer Near End of Life

Healthcare Utilization of Pediatric Patients with Cancer Near End of Life

Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life.

Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

ПОСЛЕДНЯЯ ФОРТЕПИАННАЯ СОНАТА Ф. ШУБЕРТА: ОБРАЗ ПОГРАНИЧНОГО БЫТИЯ

The article is dedicated to the last piano sonata by Franz Schubert. The Sonata B-flat major is written in the composer’s last year of life. The first great compositor of the era of musical romanticism inherited from the Viennese classics sonata form, principles of musical drama, characteristic features of the polyphonic tissue organization. At the same time, in the sonata he introduces elements of variation development that extensively expand the sonata’s allegro. The song and dance genres characteristic of Schubert’s instrumental music play an important role in the Sonata B-flat major. Multi-genre deepens the figurative sphere, complicates musical dramaturgy. On the border between Viennese classicism and emerging romanticism, there is a particular tension. Here it is possible to cross previously impassable boundaries – tonal, scale, genre and figurative. The presentiments of a near end of life have left their mark on all of Sonata’s music. The world of content is filled with extra-musical meanings, each one becoming a perspective of the theme – a transition from being to being. The first part tells about the life of a lyric hero standing at the last line. The second one is about crossing this boundary, and it’s about an imaginary crossing of a river. The river separates the world of the living from that of the dead. The third part is Skerzo – the ghost world of memories. The finale is dedicated to overcoming the delicate imperative of the minor, searching for a way into the light world, illuminated by the radiant tonality of B-flat major.

INTENTION TO USE HOSPICE CARE FOR FAMILY AMONG OLDER RURAL BLACK AMERICANS IN ALABAMA

Abstract Hospice usage overall continues to rise however, remains low among people of color, including by Black/African Americans. In 2020, 50.8% of White Medicare decedents and only 35.5% of Black decedents used hospice (NHPCO, 2022). Often reasons are connected to poor knowledge of and access to hospice resources that provide holistic support to those near end of life and their caregivers (Adrien, 2017). Little is known about the intention of older rural Black Americans’ to use hospice when caring for family members at home. In this study, older African Americans in Black Belt communities in Alabama were recruited to participate in a survey that addressed health literacy of problems with high prevalence in this rural area (diabetes, cardiovascular disease, stroke and cancer) (CDC Interactive Atlas, 2022). Guided by the Andersen’s Behavioral Model of Health Services Use, regression analysis was conducted to identify predisposing, enabling, and need factors influential in older rural African Americans’ intention to use hospice for family members. Among non-caregivers, who had heard of hospice (n=118 of 180), education, gathering with friends and social club participation, and PHQ-9 were found influential in predicting intention to use hospice for family members. However, among caregivers (n=107), female gender, education, health literacy, gathering with friends, social club participation, and PHQ-9 were influential. Results point to interventions to bolster health literacy regarding hospice among older rural Black Americans and that social clubs and other gathering places could be targeted with educational programs to increase intention to use hospice care for family members.

BLACK CAREGIVERS’ CULTURAL, RELIGIOUS, AND SYMPTOM MANAGEMENT EXPERIENCES WITH HOME HOSPICE CARE

Abstract Informal Black or African American (Black/AA) caregivers are at high risk for caregiver burden due to both greater caregiving responsibilities and unmet needs. However, there has been minimal research on the challenges Black/AA caregivers face after hospice enrollment. This study seeks to address this knowledge gap by applying qualitative methods to understand Black/AA caregivers’ experiences around cultural, religious, and symptom management challenges during home hospice care. Data from semi-structured interviews with 11 bereaved Black/AA caregivers of patients who received home hospice care were qualitatively analyzed. Cultural needs (e.g., knowing their language, having familiarity with foods) were perceived as not on top of mind for many Black/AA caregivers. However, there was concern of stigma around mental health preventing care recipients from sharing their mental health concerns and seeking resources. Many caregivers relied on their personal religious networks rather than services provided by hospice chaplains. Regarding symptom management, caregivers struggled most with managing patients’ pain, lack of appetite, and decline near End of Life (EoL). Lastly, caregivers reported increased burden during this phase of caregiving but were satisfied with the overall hospice experience. Our results suggest that tailored approaches that target mental health stigma in the Black/AA community and reduce caregiver distress around EoL symptoms may improve hospice outcomes among Black/AA hospice caregivers. Hospice spiritual services should consider offering services complementary to caregivers’ existing religious networks. Larger quantitative studies are needed to examine the clinical implications of these results in terms of patient, caregiver and hospice outcomes.

P10: Feasibility of a Longitudinal Audiovisual Observation Protocol to Characterize EL in Advanced AD/ADRD

Background:Episodes of lucidity (EL) are clinically and potentially epidemiologically significant events that occur among individuals with advanced dementia. EL are characterized by a spontaneous return of abilities previously thought to have been lost and are predominantly reported near end of life. Audiovisual observation offers a valuable approach to studying EL, providing opportunities to characterize verbal/non-verbal features of EL as well as their surrounding contexts. Approaches to capturing and characterizing audiovisual data and potential verbal/non-verbal indicators of EL near end of life are lacking.Objective:This study determined the acceptability and feasibility of a multi-faceted observational study protocol to characterize potential observable indicators of EL among people with advanced dementia near end of life.Methods:This study incorporated longitudinal audiovisual observation, informant field interviews/case review of potential EL events by informants. We examined enrollment and retention rates, task load and usability ratings from clinician and research staff across data collection and processing tasks, and surveys and qualitative appraisal from participants and staff regarding feasibility and acceptability. The NASA TLX Task Load Index measures workflow assessment to generate a combined score between 0-20, with 0 indicating higher workflow assessment. The modified System Usability Scale (SUS) measures usability with a score of 0-100, with 100 indicating higher usability and a target score ≥68 indicating usability higher than 50% of the average score.Results and Conclusion:Five eligible individuals were enrolled, yielding a 100% enrollment/retention rate, and 103 observations totaling 280 hours of observation across participants. NASA TLX Task Load Index scores of 2.9 over 4 months, with vast improvement over time indicate study procedures with iterative refinements were feasible. Average modified SUS score for clinician and research staff was 96 and 82.4 respectively, indicating high usability with notable improvement over time. Surveys and qualitative appraisal from participants and staff endorse high rates of acceptability and feasibility. Additionally, the study team identified 9 potential EL across 3 participants. Seven caregivers and two clinicians participated in case reviews to review the corresponding audiovisual data, resulting in 3 endorsed EL.

Triage for palliative radiotherapy by clinical specialist radiation therapists: A scoping review.

Patients who could benefit from palliative radiotherapy (PRT) may be in different phases of the cancer journey: they may have minimal symptoms and preserved functional status, or could be near end of life, with multiple complex care needs. Efficient triage at PRT referral is crucial to match patients with an appropriate provider and care setting as quickly as possible. Many centres have a dedicated PRT clinic, for which triage occurs by a Palliative Clinical Specialist Radiation Therapist (PCSRT). We performedan English-language literature search of 15 databases, without date limits, based on the PICO framework. After independent screening of titles and abstracts by two authors, relevant full text papers were reviewed. Twenty studies (15 publications and five abstracts) and one government report met inclusion criteria. Studies were published over a 21-year period by investigators from four countries. By identifying bottlenecks, screening out inappropriate referrals, and assessing patients in advance of consult, PSCRT triage decreased wait times by approximately 50%, on average, compared to standard pathways (range 30-82%). Increasing efficiency by pre-booking and coordinating appointments increases patient volumes and optimizes use of resources. A triage PCSRT serving a navigator role improves continuity of care, and in decreasing the number of handoffs, safety as well. Shifting triage to a PCSRT allows multidisciplinary team members to work to their maximum scope. In one clinic, after incorporation of PCSRT triage, use of on-call services decreased, as more patients were seen during daytime appointments, contributing to cost-savings.

Black Caregivers' Symptom Management, Cultural, and Religious Experiences With Home Hospice Care.

Informal Black or African American (Black/AA) caregivers are at high risk for caregiver burden due to both greater caregiving responsibilities and unmet needs. However, there has been minimal research on the challenges Black/AA caregivers face after hospice enrollment. This study seeks to address this knowledge gap by applying qualitative methods to understand Black/AA caregivers' experiences around symptom management, cultural, and religious challenges during home hospice care. Data from small group discussions with 11 bereaved Black/AA caregivers of patients who received home hospice care were qualitatively analyzed. Caregivers struggled most with managing patients' pain, lack of appetite, and decline near end of life (EoL). Cultural needs (e.g., knowing their language, having familiarity with foods) were perceived as not on top of mind for many Black/AA caregivers. However, there was a concern of stigma around mental health preventing care recipients from sharing their mental health concerns and seeking resources. Many caregivers relied on their personal religious networks rather than services provided by hospice chaplains. Lastly, caregivers reported increased burden during this phase of caregiving but were satisfied with the overall hospice experience. Our results suggest that tailored approaches that target mental health stigma in the Black/AA community and reduce caregiver distress around end of life symptoms may improve hospice outcomes among Black/AA hospice caregivers. Hospice spiritual services should consider offering services complementary to caregivers' existing religious networks. Future qualitative and quantitative studies should examine the clinical implications of these results in terms of patient, caregiver, and hospice outcomes.

End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting.

Receipt of antineoplastic systemic treatment near end of life (EOL) has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit and emergency department use, and drive-up costs; yet, these rates have not declined. To understand factors contributing to use of antineoplastic EOL systemic treatment, we explored its association with practice- and patient-level factors. We included patients from a real-world electronic health record-derived deidentified database who received systemic therapy for advanced or metastatic cancer diagnosed starting in 2011 and died within 4 years between 2015 and 2019. We assessed use of EOL systemic treatment at 30 and 14 days before death. We divided treatments into three subcategories: chemotherapy alone, chemotherapy and immunotherapy in combination, and immunotherapy (with/without targeted therapy), and estimated conditional odds ratios (ORs) and 95% CIs for patient and practice factors using multivariable mixed-level logistic regression. Among 57,791 patients from 150 practices, 19,837 received systemic treatment within 30 days of death. We observed 36.6% of White patients, 32.7% of Black patients, 43.3% of commercially insured patients, and 37.0% of Medicaid patients received EOL systemic treatment. White patients and those with commercial insurance were more likely to receive EOL systemic treatment than Black patients or those with Medicaid. Treatment at community practices was associated with higher odds of receiving 30-day systemic EOL treatment than treatment at academic centers (adjusted OR, 1.51). We observed large variations in EOL systemic treatment rates across practices. In a large real-world population, EOL systemic treatment rates were related to patient race, insurance type, and practice setting. Future work should examine factors that contribute to this usage pattern and its impact on downstream care.

The establishment, maintenance, and adaptation of high- and low-impact chronic pain: a framework for biopsychosocial pain research.

The establishment, maintenance, and adaptation of high- and low-impact chronic pain: a framework for biopsychosocial pain research.

Medication misuse and overuse in community-dwelling persons with dementia.

Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.

Trends of using immune checkpoint inhibitors near end of life in limited resources setting: Experience of single cancer center in the MENA region.

6566 Background: Immune checkpoint inhibitors (ICIs) are standard of care nowadays in the treatment of many solid tumors as single agent or in combination. Recent literature suggested increased use of ICI near end of life; our aim was to find the characteristics of the patients who received ICI 30 days or less before their death. Methods: Data of patients with advanced solid tumors who have (ICI) therapy and died with disease were retrospectively retrieved. Patients were categorized into those dying within 30 days of the last dose of ICI and those receiving the last dose of ICI more than 30 days before death. Variables of potential interest were compared between the two groups by the Chi-square and independent sample t-tests as appropriate. Results: A total of 411 patients were included in this analysis; 135 (33%) received the last dose of ICI within 30 days of death and 276 (67%) received their last dose more than 30 days before death. Major cancer types included: lung (n=214; 52%), kidney (n=61; 15%), melanoma (n=44; 11%), head and neck (n=41; 10%), and others (n=14; 3%). Patients’ characteristics: median age = 58, majority were males (310; 75%), 105 (26%) had ECOG PS ≥3, and 147 (36%) had brain metastasis. Patients who received the last dose of ICI within 30 days of death had more frequent ICU admissions (50 (37%) vs. 60 (22%), p=0.001, and were less likely to die under the care of the hospice care service (22 patients (16%) vs. 84 (31%), p=0.001. In addition, patients who received the last dose of ICI within 30 days of death were more likely to have a full code status (89 (66%) vs. 147 (53%), p=0.015, and have received a lower number of doses of ICI treatments (mean number of doses: 4.2 vs. 6.5 doses, p=0.001). We did not observe any significant difference between the two groups regarding type of cancer, age, gender, ECOG PS, presence of brain metastasis, number of hospital admissions, dying inside hospital, and number of emergency room visits. Conclusions: Immune checkpoint inhibitors may be overused near end of life which leads to minimal clinical benefits, less likelihood of dying under hospice care, and utilization of ICU resources.

Knowledge Gaps in End-Of-Life Family Caregiving for Persons Living With Dementia: A Study of Hospice Clinician Perspectives.

More than 35% of hospice care recipients 65 and older have a dementia diagnosis. Yet family care partners of persons living with dementia report feeling unprepared to address their hospice recipient's changing needs nearing end of life. Hospice clinicians may have unique insight into the knowledge needs of family care partners and strategies for end-of-life dementia caregiving. Semi-structured interviews were conducted with 18 hospice physicians, nurse practitioners, nurses, and social workers. Interview transcripts were deductively analyzed using thematic analysis to examine clinicians' perspectives on gaps and strategies related to family care partner knowledge about end-of-life dementia caregiving. We identified 3 themes related to gaps in family care partners' knowledge: dementia is a progressive, fatal disease; end-of-life symptoms and symptom management in persons living with advanced dementia; and understanding hospice goals and guidelines. Three themes related to clinicians' strategies to increase knowledge included: providing education; teaching strategies to facilitate coping and preparedness for end-of-life care; and communicating with empathy. Clinicians perceive gaps in knowledge specific to dementia and end of life among family care partners. These gaps include a lack of understanding of Alzheimer's symptom progression and strategies to manage common symptoms. Recommendations for approaches to reduce knowledge gaps include providing education and strategies delivered with empathy toward the family care partner experience. Clinicians who work with persons living with dementia receiving hospice care have valuable insights regarding family care partners' gaps in knowledge. Implications on the training and preparation of hospice clinicians working with this care partner population are discussed.

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Patients With Cognitive Impairment and Their Caregivers.

Advance care planning (ACP) conversations are important to provide goal-concordant care (i.e., the care that matches the patient's previously stated goals) near end of life. While 31% of older adults presenting to the emergency department (ED) have dementia, only 39% have previously had ACP conversations. We refined and piloted an ED-based, motivational interview designed to stimulate ACP conversations (ED GOAL) for patients living with cognitive impairment and their caregivers. We systematically refined ED GOAL and then conducted an acceptability study in an urban, academic medical center. We prospectively enrolled adults aged 50+ with cognitive impairment and their caregivers. Trained clinicians conducted the intervention. We measured acceptability after the intervention and participants' ACP engagement at baseline and 1-month follow-up. Specific statements to address both the patient and caregiver were added to the ED GOAL script. Of 60 eligible patient/caregiver dyads approached, 26 participated, and 20 (77%) completed follow-up assessments. Patient mean age was 79 years (SD 8.5); 65% were female, 92.3% were White, 96.2% were non-Hispanic, and 69% had moderate dementia. Most patients/caregivers reported feeling completely heard and understood by the study clinician about their future medical care preferences (58%, 15/26). They also reported that the study clinician was very respectful (96%, 25/26) when eliciting those preferences. Patients living with cognitive impairment and their caregivers found our refined ED GOAL acceptable and respectful. Future studies need to examine the effect of ED GOAL on ACP engagement among these dyads in the ED.

Challenges and strategies among family care partners of community-dwelling persons with dementia nearing end of life.

A growing number of persons living with dementia (PLwD) die at home with hospice care. However, there is limited information describing the needs of dying, community-dwelling persons with dementia and their family care partners (FCPs). Understanding the range of challenges faced by these FCPs is requisite to developing resources and refining support infrastructure. The current study identifies caregiving challenges unique to this population and strategies FCPs use to address those challenges. Semi-structured interviews were conducted with 40 current or recently bereaved FCPs of home hospice patients living with dementia, recruited from geriatrics clinics and a hospice agency in the New York metropolitan area. A thematic analysis guided by deductive and inductive approaches was used to code interview transcripts, identify broader conceptual categories, and search for themes. Three themes were identified related to challenges faced by FCPs: (1) managing emotions and reacting to behaviors associated with advanced dementia; (2) lack of knowledge and adequate information related to dementia: disease progression and caregiving skills; and (3) maintaining FCP well-being: self-care and caregiver burden. Three themes were identified that describe strategies FCPs of PLwD employ to cope with end-of-life caregiving demands: (1) accepting help from professional caregivers and hospice support services; (2) getting knowledge and information about dementia; and (3) pragmatic approaches and acceptance of signs and symptoms of disease progression. FCPs of PLwD near the end of life (EOL) face caregiving challenges unique to dementia and dying. While FCPs are resourceful in identifying novel strategies for managing burden and caregiving responsibilities, our results point to gaps in the current support infrastructure for this population at the EOL. Findings also identify areas of need for care partners navigating end-of-life issues.