Palliative Care Consultation Team Research Articles

Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial.

There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. One hundred thirty-two providers from PCCTs at 47 VAMCs. Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. ClinicalTrials.gov identifier: NCT02383173.

Transitioning From Hospital to Palliative Care at Home: Patient and Caregiver Perceptions of Continuity of Care

ContextContinuity of care is important at improving the patient experience and reducing unnecessary hospitalizations when transitioning across care settings, especially at the end of life. ObjectiveTo explore patient and caregiver understanding and valuation of “continuity of care” while transitioning from an in-hospital to a home-based palliative care team. MethodsLongitudinal qualitative design using semistructured interviews conducted with patients and their caregivers before and after transitioning from hospital to palliative care at home. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic analysis within a postpositivist framework. Thirty-nine participants (18 patients, seven caregivers, and seven patient-caregiver dyads) were recruited from two acute care hospitals, wherein they received care from an inpatient palliative care consultation team and transitioned to home-based palliative care. ResultsPatients had a mean age of 68 years, 60% were female and 60% had a diagnosis of cancer. Caregivers had a mean age of 62 years and 50% were female. Participants perceived continuity of care to occur in three ways, depending on which stage they were at in their hospital-to-home transition. In hospital, continuity of care was experienced, as consistency of information exchanged between providers. During the transition from hospital to home, continuity of care was experienced as consistency of treatments. When receiving home-based palliative care, continuity of care was experienced as having consistent providers. ConclusionPatients' and their caregivers’ valuation of continuity of care was dependent on their stage of the hospital-to-home transition. Optimizing continuity of care requires an integrated network of providers with reliable information transfer and communication.

Implementation of an educational intervention pilot for residents on acute care general internal medicine wards around the ‘comfort measures strategy’ for end of life care

Purpose This multi-component educational intervention was aimed at General Internal Medicine residents’ perceived self-efficacy in providing end of life care. This study also measured the uptake of the Comfort Measures Order Set. Methods This non-randomized study was conducted over nine 4-week rotations on one General Internal Medicine ward. The intervention consisted of: 1) a didactic module, 2) presence of the Palliative Care Consult Team at General Internal Medicine rounds and, 3) provision of end of life care educational materials. Twenty learners completed a pre/post Self-Efficacy in Palliative Care Scale. Data/Results Data revealed improved self-efficacy ratings on the overall scale, and on all three subscales of the Self-Efficacy in Palliative Care Scale. The Comfort Measures Order Set was implemented in 62% of patient deaths in the intervention group, and 51% of patient deaths in the control group, demonstrating no statistical difference between these groups. Conclusion The uptake of the order set in both the intervention and control groups demonstrated utility in providing a clinical framework for delivering end of life care and highlighted the need for on-going education and enhancement of clinicians' self-efficacy in end of life care.

Dutch GPs' experience of burden by euthanasia requests from people with dementia: a quantitative survey.

BackgroundIn the Netherlands during the past decade, a growing number of people with dementia requested euthanasia, and each year more of such requests were granted.AimTo obtain quantitative insights into the problems and needs of GPs when confronted with a euthanasia request by a person with dementia.Design & settingA concept survey was composed for GPs in the Netherlands. Expert validity of the survey was achieved through pilot testing.MethodA postal survey was sent to a random sample of 900 Dutch GPs, regardless of their opinion on, or practical experience with, euthanasia. Collected data were analysed with descriptive statistics.ResultsOf 894 GPs, 423 (47.3%) completed the survey, of whom 176 (41.6%) had experience with euthanasia requests from people with dementia. Emotional burden was reported most frequently (n = 86; 52.8%), as well as feeling uncertain about the mental competence of the person with dementia (n = 77; 47.2%), pressure by relatives (n = 70; 42.9%) or the person with dementia (n = 56; 34.4%), and uncertainty about handling advance euthanasia directives (AEDs) (n = 43; 26.4%). GPs would appreciate more support from the following: a support and consultation in euthanasia in the Netherlands (SCEN) physician (an independent physician for support, information, and formal consultation around euthanasia) (n = 291; 68. 8%); a geriatric consultation team (n = 185; 43.7%); the end-of-life clinic (n = 184; 43.5%); or a palliative care consultation team (n = 179; 42.3%). Surprisingly the need for moral deliberation was hardly mentioned.ConclusionThe reported burden and the rise in numbers and complexity of euthanasia requests from people with dementia warrants primary care support. There needs to be easier access to colleagues with expertise, and training on end-of-life care needs of patients with dementia and their caregivers.

Growth and Challenges in Hospital Palliative Cancer Care Services: An Analysis of Nationwide Surveys Over a Decade in Japan

ContextThe development of palliative care services is a public health priority. The Japanese Cancer Control Act has been promoting palliative care services nationwide for over 10 years. ObjectivesTo evaluate long-term changes in the structure and processes of hospital palliative cancer care services nationwide. MethodsThis was an observational study using three representative questionnaire surveys between 2008 and 2018. The questionnaire consisted of domains on the structure and process regarding hospital palliative cancer care services. The changes over time were assessed using the MacNemar test. The differences between groups, namely community hospitals and designated cancer hospitals, were determined using χ2 tests. ResultsWe analyzed changes over time from 281 designated cancer hospitals and compared the services between 1395 community hospitals and 380 designated cancer hospitals. The development of the structure and processes for designated cancer hospital's palliative cancer care services was greater for 10 years including the number of Palliative Care Consultation Teams (PCTs) with more than 50 patient referrals annually (from 2010 to 2018: 76.2% to 85.4%, P < 0.001). The palliative cancer care services of community hospitals were poorly prepared compared with designated cancer hospitals in 2018, such as the “direct medical care by any member of the Palliative Care Consultation Team at least 3 times a week (41.7% vs. 81.3%; P < 0.001). ConclusionHospital palliative cancer care services in designated cancer hospitals have developed significantly from 2008 to 2018. Building a system to promote palliative care services in community hospitals is a challenge for the next decade.

Accuracy of the Palliative Prognostic Score With or Without Clinicians' Prediction of Survival in Patients With Far Advanced Cancer

ContextPrevious studies suggest that clinicians' prediction of survival (CPS) may have reduced the accuracy of objective indicators for prognostication in palliative care. ObjectivesWe aimed to examine the accuracy of CPS alone, compared to the original Palliative Prognostic Score (PaP), and five clinical/laboratory variables of the PaP in patients with far advanced cancer. MethodsWe compared the discriminative accuracy of three prediction models (the PaP-CPS [the score of the categorical CPS of PaP], PaP without CPS [sum of the scores of only the objective variables of PaP], and PaP total score) across 3 settings: inpatient palliative care consultation team, palliative care unit, and home palliative care. We computed the area under receiver operating characteristic curve (AUROC) for 30-day survival and concordance index (C-index) to compare the discriminative accuracy of these three models. ResultsWe included a total of 1534 subjects with median survival of 34.0 days. The AUROC and C-index in the three settings were 0.816–0.896 and 0.732–0.799 for the PaP total score, 0.808–0.884 and 0.713–0.782 for the PaP-CPS, and 0.726–0.815 and 0.672–0.728 for the PaP without CPS, respectively. The PaP total score and PaP-CPS showed similar AUROCs and C-indices across the three settings. The PaP total score had significantly higher AUROCs and C-indices than the PaP without CPS across the three settings. ConclusionOverall, the PaP total score, PaP-CPS, and PaP without CPS showed good discriminative performances. However, the PaP total score and PaP-CPS were significantly more accurate than the PaP without CPS.

Were Clinical Routines for Good End-of-Life Care Maintained in Hospitals and Nursing Homes During the First Three Months of the Outbreak of COVID-19? A National Register Study

ContextAlthough the coronavirus disease 2019 (COVID-19) pandemic might affect important clinical routines, few studies have focused on the maintenance of good quality in end-of-life care. ObjectivesThe objective was to examine whether adherence to clinical routines for good end-of-life care differed for deaths because of COVID-19 compared with a reference cohort from 2019 and whether they differed between nursing homes and hospitals. MethodsData about five items reflecting clinical routines for persons who died an expected death from COVID-19 during the first three months of the pandemic (March–May 2020) were collected from the Swedish Register of Palliative Care. The items were compared between the COVID-19 group and the reference cohort and between the nursing home and hospital COVID-19 deaths. ResultsAbout 1316 expected deaths were identified in nursing homes and 685 in hospitals. Four of the five items differed for total COVID-19 group compared with the reference cohort: fewer were examined by a physician during the last days before death, pain and oral health were less likely to be assessed, and fewer had a specialized palliative care team consultation (P < 0.0001, respectively). Assessment of symptoms other than pain did not differ significantly. The five items differed between the nursing homes and hospitals in the COVID-19 group, most notably regarding the proportion of persons examined by a physician during the last days (nursing homes: 18%; hospitals: 100%). ConclusionThis national register study shows that several clinical routines for end-of-life care did not meet the usual standards during the first three months of the COVID-19 pandemic in Sweden. Higher preparedness for and monitoring of end-of-life care quality should be integrated into future pandemic plans.

A Social Worker-Led Primary Palliative Care Model for Hospitalized Patients Admitted to the Hospital Medicine Service.

Objective: To increase earlier access to palliative care, and in turn increase documented goals of care and appropriate hospice referrals for seriously ill patients admitted to hospital medicine.Background: Due to the growing number of patients with serious illness and the specialty palliative care workforce shortage, innovative primary palliative care models are essential to meet this population's needs.Methods: Patients with serious illness admitted to hospital medicine at a quaternary urban academic medical center in New York City and received an embedded palliative care social worker consultation in 2017. We used univariate analyses of sociodemographic, clinical, and utilization data to describe the sample.Results: Overall, 232 patients received a primary palliative care consultation (mean age of 69 years, 44.8% female, 34% white, median Karnofsky Performance Status of 40%), and 159 (69%) had capacity to participate in a goals-of -are conversation. Referrals were from palliative care solid tumor oncology trigger program (113 [49%]), specialty palliative care consultation team (42[18%]), and hospital medicine (34[14.6%]). Before the consultation, 10(4.3%) had documented goals of care and 207 (89%) did after the consultation. The percentage of those referred to hospice was 24.1%. Of those transferred to specialty palliative care consultation service, nearly half required symptom management.Discussion: Patients who received a primary palliative care consultation were seen earlier in their illness trajectory, based on their higher functional impairment, and the majority had capacity to participate in goals-of-care discussions, compared with those who were seen by specialty palliative care. The consultation increased goals-of-care documentation and the hospice referral rate was comparable with that of the specialty palliative consultation team.

The Impact of Palliative Care Team Consultation on Quality of Life of Patients with Advanced Cancer in Dutch Hospitals: An Observational Study

Introduction: Experimental studies have shown that palliative care team (PCT) involvement can improve quality of life (QoL) and symptom burden of patients with advanced cancer. It is unclear to what extent this effect is sustained in daily practice of hospital care. Objective: This observational study aims to investigate the effect of PCT consultation on QoL and symptom burden of hospitalized patients with advanced cancer in daily practice. Methods: After admission to 1 of 9 participating hospitals, patients with advanced cancer for whom the attending physician answered “no” to the Surprise Question were invited to complete a questionnaire, including the EORTC QLQ-C15-PAL, at 6 points in time, until 3 months after admission. Outcomes were compared between patients who received PCT consultation and patients who did not, taking into account differences in baseline characteristics. Results: A total of 164 patients consented to participate, of whom 32 received PCT consultation. Of these patients, 108 were able to complete a questionnaire at day 14, of whom 19 after receiving PCT consultation. After adjusting for baseline differences, EORTC QLQ-C15-PAL scores for pain, appetite, and emotional functioning at day 14 were more favorable for patients who received a PCT consultation. Conclusion: PCT consultation decreased patients’ symptom burden and tends to have a positive effect on QoL of hospitalized patients with advanced cancer, even if the PCT is consulted late in the patient’s disease trajectory.

A mixed-methods pilot study of ‘LIFEView’ audiovisual technology: Virtual travel to support well-being and quality of life in palliative and end-of-life care patients

Background: There is evidence that psychosocial and spiritual interventions of short duration, such as reminiscence therapy, provide positive impacts on quality of life and emotional and existential well-being in adults receiving palliative care. Aim: To determine (1) the feasibility of integrating ‘LIFEView’, a video-based software with >1600 videos of world destinations, in palliative care settings, and (2) positive, neutral or harmful effects of using ‘LIFEView’ videos. Design: A mixed-methods pre–post intervention pilot study was conducted to collect feasibility and preliminary data on physical and psychological symptoms, physiological indicators, spiritual well-being and aspects of quality of life. Setting/participants: Adult patients on an inpatient palliative care unit or receiving care from a community palliative care consultation team who were capable of providing consent and completing the outcome measures were eligible participants. Results: Overall, 27/41 (66%) participants took part in the study. Feasibility criteria, including participant acceptability, low participant burden, tool completion rate and retention rate, were fulfilled, though challenges were experienced with recruitment. Modest improvements, though non-significant, were shown on preliminary data collected on physical and psychological symptoms using the Edmonton Symptom Assessment System–revised, spiritual well-being assessed by the 12-item Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being scale and physiological measurements. Qualitative analysis revealed five themes: motivations for using ‘LIFEView’, perceptions of the technology, reminiscence, ‘LIFEView’ as an adaptable technology and ongoing or future use. Conclusion: A future adequately powered study to investigate the impacts of ‘LIFEView’ on patient well-being and quality of life appears to be feasible.

Impact, challenges and limits of inpatient palliative care consultations \u2013 perspectives of requesting and conducting physicians

BackgroundInpatient palliative care consultation (IPCC) teams have been established to improve care for patients with specialist palliative care (PC) needs throughout all hospital departments. The objective is to explore physicians’ perceptions on the impact of IPCC, its triggers, challenges and limits, and their suggestions for future service improvements.MethodsA Qualitative study drawing on semi-structured interviews with 10 PC specialists of an IPCC team and nine IPCC requesting physicians from oncology and non-oncological departments of a university hospital. Analysis was performed using qualitative content analysis.ResultsPC specialists and IPCC requesting physicians likewise considered organization of further care and symptom-burden as main reasons for IPCC requests. The main impact however was identified from both as improvement of patients’ (and their caregivers’) coping strategies and relief of the treating team. Mostly, PC specialists emphasized a reduction of symptom burden, and improvement of further care. Challenges in implementing IPCC were lack of time for both. PC specialists addressed requesting physicians’ skepticism towards PC. Barriers for realization of IPCC included structural aspects for both: limited time, staff capacities and setting. PC specialists saw problems in implementing recommendations like disagreement towards their suggestions. All interviewees considered education in PC a sensible approach for improvement.ConclusionsIPCC show various positive effects in supporting physicians and patients, but are also limited due to structural problems, lack of knowledge, insecurity, and skepticism by the requesting physicians. To overcome some of these challenges implementation of PC education programs for all physicians would be beneficial.

Implementation of the BEACON II Comfort Care Order Set in Veterans Affairs (VA) Medical Centers: Palliative Care Consult Team Members' Perspectives (S705)

Implementation of the BEACON II Comfort Care Order Set in Veterans Affairs (VA) Medical Centers: Palliative Care Consult Team Members' Perspectives (S705)

Weekly Rounds with Interdisciplinary Palliative Care Consult Team and Prognostication for Hematology/Oncology Inpatients (QI652)

Weekly Rounds with Interdisciplinary Palliative Care Consult Team and Prognostication for Hematology/Oncology Inpatients (QI652)

Palliative care consultation team: symptom relief in first 48 hours of hospitalization

To compare the relief of symptoms provided by palliative care consultation team (PCCT) compared to the traditional care team (TC), in patients with advanced cancer in the first 48 hours of hospitalization. Allocated to PCCT Group and TC Group, this study assessed 290 patients according to the Edmonton Symptom Assessment System (ESAS) within the first 48 hours of hospitalization. The main outcome was a minimum 2-point reduction in symptom intensity. At 48 hours, the PCCT Group had a 2-point reduction in the mean differences (p <0.001) in pain, nausea, dyspnea, and depression; and TC Group, on nausea and sleep impairment (p <0.001). Multiple Logistic Regression found for the PCCT Group a greater chance of pain relief (OR 2.34; CI 1.01-5.43; p = 0.049). There was superiority of the PCCT Group for pain relief, dyspnea and depression. There is a need for more studies that broaden the understanding of team modalities.

The impact of palliative care consults on deprescribing in palliative cancer patients

The transition from active cancer treatment to palliative care often results in a shift in drug risk-benefit assessment which requires the deprescribing of various medications. Deprescribing in palliative cancer patients can benefit patients by reducing their pill burden, decrease potential side effects, and potentially decrease healthcare costs. In addition, a change in patients' goals of care (GOC) necessitates the alteration of drug therapy which includes both deprescribing and the addition of medications intended to improve quality of life. Depending on a patient's GOC, a medication can be considered as inappropriate. Primary: Comparison between potentially inappropriate medications (PIMs) prior to the palliative care consult (PCC) versus after the PCC. Secondary: Association between PIMs and GOC. The study was a 1-year retrospective database review. The study included cancer patients seen by the PCC team at the University of Alberta Hospital. The OncPal guidelines were used to identify and determine the number of PIMs prior to the PCC and after the PCC. The reduction in PIMs prior to PCC versus after the PCC was statistically significant (p value < 0.001), demonstrating the PCC has a positive significant impact on deprescribing PIMs. For our secondary outcome, an overall decrease in PIMs was observed with the changes of GOC. The strength of the correlations was low (r < 0.1), and the p value was 0.056. This study shows the positive impact a PCC has on deprescribing and reveals the importance of using guidelines for deprescribing in palliative cancer patients.

The association between palliative care team consultation and hospital costs for patients with advanced cancer: An observational study in 12 Dutch hospitals.

BackgroundEarly palliative care team consultation has been shown to reduce costs of hospital care. The objective of this study was to investigate the association between palliative care team (PCT) consultation and the content and costs of hospital care in patients with advanced cancer.Material and MethodsA prospective, observational study was conducted in 12 Dutch hospitals. Patients with advanced cancer and an estimated life expectancy of less than 1 year were included. We compared hospital care during 3 months of follow‐up for patients with and without PCT involvement. Propensity score matching was used to estimate the effect of PCTs on costs of hospital care. Additionally, gamma regression models were estimated to assess predictors of hospital costs.ResultsWe included 535 patients of whom 126 received PCT consultation. Patients with PCT had a worse life expectancy (life expectancy <3 months: 62% vs. 31%, p < .01) and performance status (p < .01, e.g., WHO status higher than 2:54% vs. 28%) and more often had no more options for anti‐tumour therapy (57% vs. 30%, p < .01). Hospital length of stay, use of most diagnostic procedures, medication and other therapeutic interventions were similar. The total mean hospital costs were €8,393 for patients with and €8,631 for patients without PCT consultation. Analyses using propensity scores to control for observed confounding showed no significant difference in hospital costs.ConclusionsPCT consultation for patients with cancer in Dutch hospitals often occurs late in the patients’ disease trajectories, which might explain why we found no effect of PCT consultation on costs of hospital care. Earlier consultation could be beneficial to patients and reduce costs of care.

A Self-Check Program Targeting Quality Improvement in a Hospital-Based Palliative Care Consultation Team, Japanese Society for Palliative Medicine: Issues Regarding Team Activities Identified through the Plan-Do-Check-Act Cycle.

Background: The number of hospital-based palliative care consultation teams (PCCTs) has increased in Japan, and quality improvement (QI) of PCCTs is an issue. The Japanese Society for Palliative Medicine is building a framework for continuous QI of PCCT activities. Objective: The objective of this study was to develop a program to support QI for PCCTs, and to describe the initial experience with the program. Design: The report details the development of a self-check program, followed by a one-year follow-up observational survey. Methods: We developed a self-check program using the concept of the Plan-Do-Check-Act (PDCA) cycle and a multidisciplinary expert panel. A total of 114 PCCTs entered the program in the first year. Results: We developed three forms for the CHECK, ACT-PLAN, and DO phases aligned with the PDCA cycle. The forms consisted of 34 items across 8 domains. A total of 83 PCCTs (729 members) returned the CHECK, ACT-PLAN forms, and 41 PCCTs returned the DO forms after one year. Overall, 213 high priority issues were identified in the ACT phase. The issues of many PCCTs were "Sharing goals of care is inadequate within the PCCT (33%)" and "Sharing goals of care is inadequate between patient/family or primary team and the PCCT (28%)." Improvements in identified issues were: "achieved" 23% and "almost achieved" 48% after one year. Conclusions: We developed a self-check program to support QI efforts for hospital-based PCCTs. The priority issues among PCCTs and improvement goals with examples were identified. These results will support ongoing efforts to develop a continuous improvement model for QI of PCCTs.

The COMPASS study: A descriptive study on the characteristics of palliative care team consultation for cancer patients in hospitals.

To describe the characteristics of palliative care team (PCT) consultation for patients with cancer who are admitted in hospital and to investigate when and why PCTs are consulted. In this descriptive study in ten Dutch hospitals, the COMPASS study, we compared characteristics of patients with cancer for whom a PCT was or was not consulted (substudy 1). We also collected information about the process of PCT consultations and the disciplines involved (substudy 2). In substudy 1, we included 476 patients. A life expectancy <3months, unplanned hospitalisation and lack of options for anti-cancer treatment increased the likelihood of PCT consultation. In substudy 2, 64% of 550 consultations concerned patients with a life expectancy of <3months. The most frequently mentioned problems that were identified by the PCTS were complex pain problems (56%), issues around the organisation of care (31%), fatigue (27%) and dyspnoea (27%). There was much variance between hospitals in the disciplines that were involved in consultations. Palliative care teams in Dutch hospitals are most often consulted for patients with a life expectancy of <3months who have an unplanned hospital admission because of physical symptoms or problems. We found much variance between hospitals in the composition and activities of PCTs.

Impact of specialist palliative care delivered over three months prior to death on a colorectal cancer patient’s risk of experiencing aggressive end-of-life care.

6614 Background: More patients are experiencing aggressive end-of-life (EOL) care. This is concerning as aggressive EOL care, on a population level, is associated with poor quality care. Specialist palliative care (PC) has been shown to help relieve EOL symptoms, improve patient quality of life, and reduce aggressive EOL care. This study aimed to estimate the impact of the timing of specialist PC, specifically PC delivered at least 3 months prior to death, on a colorectal cancer (CRC) patient’s risk experiencing aggressive care in the last 30 days of life. Methods: A population-based retrospective cohort study of adult patients who died from CRC in Alberta, Canada from 2011-2015. The Alberta Cancer Registry was used to identify the cohort, which was linked to healthcare resource use data in local, provincial, and national databases. Individuals who died &lt; 30 days from CRC diagnosis were excluded. Patients who accessed any of the provinces specialist PC services were deemed exposed to specialist PC (includes PC consult team, intensive PC unit, palliative home care, hospice). Aggressive EOL care was defined as having experienced at least one of: hospital death, &gt; 1 emergency department visit, &gt; 1 hospital admission, &gt; 14 days of hospitalization, ≥1 intensive care unit admission, ≥1 new chemotherapy program (or any treatment in the last 14 days of life). Logistic regression was used to model factors (specialist PC timing and clinical characteristics) associated with aggressive EOL care. Results: The cohort comprised 2979 patients. Most patients received specialist PC before death (58%); 60% had ≥1 indicator of aggressive EOL care. Relative to patients who received specialist PC &gt; 3 months before death, patients who received specialist PC &lt; 3 months before death were 1.5 times more likely to experience aggressive EOL care (CI: 1.2-1.9). Patients who received no specialist PC were 2.1 times more likely to experience aggressive EOL care (CI: 1.7-2.8). Short disease duration ( &lt; 1 year from diagnosis to death), younger age at death, living in a rural area, and male sex, were also associated with higher odds of experiencing aggressive EOL care. Conclusions: Specialist PC delivered &gt; 3 months before death reduces a CRC patient’s risk of experiencing aggressive EOL care over PC delivered &lt; 3 months before death.

Characteristics of Peri-Transplant Palliative Supportive Care Consultation Among Older Allogeneic Hematopoietic Cell Transplant Recipients

Background Recent studies have shown that provision of palliative care (PC) simultaneously with hematopoietic cell transplant (HCT) is feasible and effective in improving symptom burden and improving mood during and in the first 6 months after transplant. However, given the scarce PC resource, it is important to explore the population of HCT patients who will benefit the most from subspecialty PC and its optimal timing. Methods We retrospectively examined all peri-transplant palliative supportive care consultations for patients aged 60 years and older who underwent first allo-HCT at our institution from 2001 to 2017 through chart review. We included all PC consultations from 6 months prior to and 6 months following HCT and systemically characterized each individual consultation. Predictors and potential impact of PC consultations were analyzed. Results 70 patients (11%) among a total of 610 patients, received a PC consultation during the period and were included. Table 1 depicts the baseline clinical and transplant characteristics. The median time of PC consultation from HCT was 14.5 days and there were 9 consultations prior to HCT. The majority of PC consultation, 86%, were conducted as inpatient; and 91% were initiated by the transplant team. The primary consult reason was overwhelmingly pain management, 77%, followed by the management other symptoms, goals of care discussion, and end-of-life care. In 17 patients, 24%, additional palliative care needs were identified by the consult team. The median number of visits was 5 (range 1-23). Only three patients had outpatient follow-up after initial inpatient consultation. By June 30, 2018, 48 patients, 69%, had died. The median time from PC consultation to death was 37.5 days, with 5 patients, 10%, enrolled in hospice prior to death. We are examining independent association of pre-transplant variables with PC consultations and their impact on HCT outcomes. Conclusions While limited by its retrospective nature, this study provides an overview of PC consult utilization in an older cohort of allogeneic HCT patients, which is likely the most symptomatic population with the highest risk for adverse outcomes. These results suggest that the transplant team may not have utilized the subspecialty PC consult to its complete potential. Future studies will attempt to prospectively assess patient reported outcomes and the impact of interdisciplinary PC consult team.