Palliative Care Group Research Articles

Palliative care referral in ST-segment elevation myocardial infarction complicated with cardiogenic shock in the United States

BackgroundST-segment elevation myocardial infarction complicated with cardiogenic shock (STEMI-CS) is associated with high mortality but the trends of utilization and predictors of palliative care (PC) referral in this population have not been well described. ObjectivesTo investigate the utilization trends and predictors of PC referral in STEMI-CS. MethodsNationwide inpatient sample from 2005–2014 was queried to identify patients with STEMI-CS of age ≥18. PC referral was identified International Classification of Diseases, Ninth Edition Clinical Modification, V66.7. ResultsA total of 33,294 admissions were identified and 1,878 (5.6%) had PC encounter. PC referral group were older and had higher comorbidities. PC consultation increased approximately 10 times over the study period in those who died (from 2.3% to 27.4%) and in those who survived (from 0.21% to 2.83%). In multivariable analysis, age, higher Exlixhauser score, no revascularization, teaching hospital, large bed hospital, mechanical circulatory support use, and lower income status were associated with increased PC referral whereas coronary artery bypass graft was associated with lower PC referral rates. Patients under PC group were more often discharged to an extended care facility and less likely discharged home. ConclusionPC utilization increased substantially during the 10-years study period in the United States in STEMI-CS. Several baseline, procedural, hospital, and socioeconomic factors were associated with PC referral in the setting STEMI-CS.

EARLY VS USUAL PALLIATIVE CARE CONSULTATION IN THE ICU: AUGMENTING THE CRITICAL CARE PHYSICIAN TO DECREASE IN-HOSPITAL MORTALITY

SESSION TITLE: Palliative Care and End-of-Life SESSION TYPE: Original Investigations PRESENTED ON: 10/20/2019 2:15 PM - 3:15 PM PURPOSE: Around 1/5 of all deaths in the USA occur in or around an Intensive Care Unit (ICU) admission. This admission may result in changing goals of care from cure to comfort, but sometimes too late. Palliative care medicine’s (PCM) role as defined by Institute of Medicine is to “prevent, relieve, reduce, or soothe the symptoms of disease or disorder without effecting a cure” so they are a specialty that would assist with this transition. Researchers have shown a decreased length of stay and costs when PCM was involved early in the ICU stay. Other studies have tried to show an improvement in patient and family member/caregiver satisfaction scores, but have failed due to low sample sizes. There have been no studies to compare if an early palliative care consult (within 24 hours) improves mortality or decreases hospital deaths when compared to usual palliative care consultation (whenever the treating team deems is appropriate). METHODS: We performed a randomized controlled trial in a medical ICU (MICU) from 10/1/2018 to 11/30/2018. Adult patients were included if they met just one of these criteria 1) age>80 years, 2> APACHE II score >14, 3) SOFA score >9, 4) Pre-existing functional dependency, 5) late stage dementia, 6) metastatic cancer, 7) consideration to place a permanent feeding tube or tracheostomy, 8) recurrent ICU admissions, 9) post-cardiac arrest, or 10) end stage organ failure. Patients were excluded if they have already seen palliative care medicine. Once included in the study, the patients were randomized to either group by a random number generator. The patients randomized to the treatment group had a palliative care consultation within 24 hours of MICU admission. RESULTS: A total of 29 patients were randomized (14 in the early and 15 in the usual palliative care group). Baseline patient characteristics were not different between groups. The early palliative care group had a lower hospital mortality when compared to the usual care group (0 vs 6; p=0.04). More patients were discharged to hospice in the early group (4 vs 0; p=0.01). There also were more healthcare surrogates chosen in the hospital in the early group (7 vs 0; p<0.01). There was no difference in ICU or hospital length of stay or code status changes. CONCLUSIONS: This is the only study that has been performed to evaluate early palliative care consultation as defined as within 24 hours of ICU admission and its impact in patient care. We have shown in this study that patients who receive an early palliative care consultation have a lower in-hospital mortality resulting in more discharges to hospice. Also, this study shows that more healthcare surrogates are chosen in the hospital when palliative care medicine is involved earlier. CLINICAL IMPLICATIONS: Palliative care is able to augment the Critical Care physician's ability to take care of end-of-life patients when involved early resulting in a lower ICU and hospital mortality. DISCLOSURES: No relevant relationships by Rebecca Burnside, source=Web Response No relevant relationships by Scott Helgeson, source=Web Response No relevant relationships by John Moss, source=Web Response No relevant relationships by Maisha Robinson, source=Web Response

Quality of Life of Patients with Advanced Cancer in Palliative Therapy and in Palliative Care

Objective: To assess the quality of life of patients with advanced cancer in palliative therapy and in palliative care. Materials and Methods: Quantitative, observational, cross-sectional, and analytic study conducted in a teaching hospital in Paraná, Brazil, from January to June 2018, with 126 patients: 107 in palliative therapy; 19 in exclusive palliative care. The questionnaires for data collection were: Quality of Life Questionnaire-Core 15-Palliative, Functional Assessment of Chronic Illness Therapy-Palliative Care 14, and Edmonton Symptom Assessment System. The Spearman non-parametric coefficient test was used for the analysis. Results: The overall quality of life in palliative therapy and in palliative care was, respectively, 71.54/59.65; when correlating the total score of quality of life of the Quality of Life Questionnaire-Core 15-Palliative with the Functional Assessment of Chronic Illness Therapy-Palliative Care 14 (p = 0.001), and the Edmonton Symptom Assessment System (p = 0.001), significant difference of better quality of life was observed in the palliative therapy. Conclusion: Patients in palliative therapy have good overall quality of life, while the palliative care group reports regular quality of life. The symptoms were milder in the palliative therapy and more intense and with greater significance in palliative care; hence, knowing the compromise of quality of life will help professionals in planning interventions with transdisciplinary approach for patients and for their families.

Increasing Joy for Pediatric Palliative Care Providers: #PACTimpact a Quality Improvement Initiative for Resiliency in the Workplace

Our pediatric palliative care group is called the “Pediatric Advanced Care Team,” also known as “PACT.” We created a novel system called #PACTimpact to identify situations in which team members go above and beyond for patients providing meaningful impact for our families. We hypothesize that by recognizing the impact we make on families we will bring more joy in the workplace ultimately facilitating improved resiliency. These impacts may be big or small such as conducting an afterhours home visit or bringing a parent a coffee. Problem statement: Pediatric palliative care …

Clinical Effectiveness of Endoscopic Stent Placement in Treatment of Acute Intestinal Obstruction Caused by Colorectal Cancer

BackgroundEmergency endoscopic intestinal stenting has been applied with increasing frequency in colorectal cancer patients with acute intestinal obstruction. However, its clinical effectiveness as compared to emergency surgery remains controversial.Material/MethodsThe clinical data of 96 patients with acute intestinal obstruction caused by colorectal cancer from April 2012 to April 2018 were retrospectively collected. Statistical technique success rate, clinical success rate, operative time, average indwelling time of stent, complications, transition time to second-stage surgery, postoperative hospital stay, sputum rate, and postoperative infection rate were studied.ResultsEndoscopic colonoscopy was successfully performed in 94 patients. The success rate of stent placement was 97.9%, and the average operative time was 35 minutes (range, 25–85 minutes). Forty-two patients underwent stage I colectomy after relief of the obstruction. The average stent retention time was 7 days (range, 5–15 days). Two patients suffered from anastomotic infection. Their intestinal preparation time, hospital stay, fistula rate, and infection rate were lower than those of patients undergoing emergency operation for colon cancer intestinal obstruction. A total of 52 patients with colon cancer underwent palliative stent placement. Three patients had complications, including 1 case of stent displacement in the palliative care group and 2 cases with perforation in the bridge surgery group.ConclusionsEmergency endoscopic placement of an intestinal stent is safe and effective in the treatment of patients with acute intestinal obstruction caused by colorectal cancer. It is also a safe and simple procedure for patients receiving advanced palliative treatment, which greatly improves their quality of life and is easy for patients’ families to accept.

Which role plays specialized palliative care in patients with relapsed and/or metastatic head and neck cancer? A retrospective analysis in Southern Switzerland.

e17503 Background: early palliative care (PC) for patients with advanced cancer improves quality of life, promotes home deaths and can improve survival. Limited data are available regarding PC in advanced head and neck cancer (HNC) patients. To investigate the effect of introducing specialized PC in patients with relapsed and/or metastatic head and neck cancer. Methods: between October 2010 and December 2018, the medical charts of all patients treated in the Oncology Institute of Southern Switzerland with relapsed and/or metastatic HNC were reviewed. Site, status of disease (metastatic at diagnosis, locally or metastatic relapsed), type and lines of treatment, treatment response and referral to specialist palliative care (yes or no) were documented. Comparisons were made between patients referred and non-referred to PC. Results: sixty-two patients with relapsed/metastatic HNC were identified, 32 (51.6%) of which were referred to specialized PC. Patients were mainly men (47, 75.8%), with a median age of 66 years (range 43 – 86). Forty-two patients (67.7%) had a metastatic disease and the most common site of tumor was the oropharynx (35.5%), followed by oral cavity (32.3%), larynx (16.1%), hypopharynx (12.9%), and unknown primary (3.2%). Forty-eight patients (77.4%) were treated with systemic treatment (75% in the PC group and 80% in the non-PC group, p = 0.638). The median overall survival was 8.1 months for all patients, 8 months for the PC group and 8.7 months for the non-PC group, without significant difference (p = 0.440). Of the deceased patients, 70% of the PC group and 73.3% of the non-PC group received chemotherapy in the last three months of life. A greater percentage of patients in the PC group died at home, but without significant difference (39.2% vs. 19%, p = 0.134). Conclusions: only half of the patient had access to specialized PC. Whereas it did not seem to affect overall survival nor influence chemotherapy prescription, it seemed to favor home deaths. Further studies investigating the impact of early PC in recurrent and/or metastatic HNC are needed to improve access to PC and maximize benefits.

A community oncology end-of-life care program: Results for hospice length of stay analysis.

e23008 Background: Michigan Health Professionals (MHP) is a large multispecialty physician group. MHP Oncology Division participates in quality improvement projects. Palliative and End of Life (EOL) care has been identified as one of the quality improvement areas. A comprehensive community oncology program for early and timely involvement of palliative and EOL care was launched in October 2017. Methods: MHP Palliative and End of life care committee was created of mostly oncologists who are board certified in Palliative care and Hospice. The program, which included pre-program training, user-friendly referral process, and live physician engagement for early involvement of palliative care (PC) and EOL care was developed and implemented. A partnership was created with Premier Hospice to integrate EOL care services with the oncology offices and to collect data. Historical data for average hospice length of stay (LOS) in hospice service for MHP oncology patients was analyzed by Integra Connect. Results: From 1/1/2018 to 12/31/2018 a total of 133 patients (MHP-T) were referred and admitted to Hospice service. Sixty-one patients were on PC service (PC group) and 72 patients (NonPC group) were referred directly to hospice. Total of 527 patients from 2012 to 2017 were analyzed for historical comparison group (HC) and 124 patients were analyzed for MHP-T group. Average LOS was 16.8 days in the HC group. Average LOS for the MHP-T, PC group and NonPC group improved to 34, 35 and 33 days respectively. HC group had 82.2% of patients with average LOS &lt; 30 days. After program implementation average LOS &lt; 30 days improved to 63.7% MHP-T group, 60.0% PC group and 66.7% NonPC group. In HC group, 92 out of 527 patients had average LOS of 2 days or less. Only 2 patients out of 124 patients had average LOS of 2 days or less since the launch of MHP community oncology program. Conclusions: Early and timely patient referral to the EOL care services resulted in average hospice LOS which is more than double as compared to historical comparison group. Fewer number of patients had average LOS of &lt; 30 days and LOS of 2 days or less as compared to the historical comparison group. There was a trend towards higher LOS observed for patients who were under palliative care (PC) before hospice admission.

The association of financial difficulties and out-of-pocket payments with health-related quality of life among breast, prostate and colorectal cancer patients

Objectives: Financial difficulties experienced by cancer patients may affect their health-related quality of life (HRQoL). This study assessed the direct economic burden that out-of-pocket (OOP) payments cause and explored how they and financial difficulties are associated with HRQoL.Methods: This is a cross-sectional registry and survey study of 1978 cancer patients having either prostate (630), breast (840) or colorectal cancer (508) treated in Finland. The patients were divided into five groups according to the stage of their disease: primary treatment, rehabilitation, remission, metastatic disease and palliative care. The cost data and OOP payments were retrieved from primary and secondary healthcare registries, the Social Insurance Institution of Finland, and a patient questionnaire. HRQoL was measured by 15D, EQ-5D-3L and by EORTC-QLQ-C30. Financial difficulties were evaluated based on patients’ self-assessment in the EORTC-QLQ-C30 four-level question about financial difficulties. A path analysis was used to explore the relationship between clinical and demographic factors, HRQoL, OOP payments and financial difficulties.Results: The highest OOP payments were caused by outpatient medication. Total costs and OOP payments were highest in the palliative care group in which the OOP payments consisted mostly of outpatient medication and public sector specialist care. Private sector health care was an important item of OOP payments in the early stages of cancer. Financial difficulties increased together with OOP payments. HRQoL deteriorated the more a person had financial difficulties. In the path analysis, financial difficulties had a major negative direct and total effect on the HRQoL. Factors that attenuated financial difficulties were age, cohabiting and higher education and factors that increased them were OOP payments, total costs of healthcare use, and unemployment.Conclusions: High OOP payments are related to financial difficulties, which have a negative effect on HRQoL. Outpatient medication was a major driver of OOP payments. Among palliative patients, the economic burden was highest and associated with impaired HRQoL.

Loss of relationship: a qualitative study of families and healthcare providers after patient death and home-based palliative care ends.

Home-based palliative care is care of the patient in their home, while doctors and other healthcare providers (HCPs) make visits as required. Family involvement naturally cultivates a relationship between HCPs and the family. Once the patient dies and home-based palliative care ends, this relationship is abruptly terminated, which may be challenging to both the family and the HCPs. The objective of this study was to understand the thoughts and opinions of HCPs and families on their encountered loss of relationship at the end of home-based palliative care. Perceptions of 63 participants (32 HCPs and 31 family members) were explored using semi-structured interviews and the qualitative research methodologies of grounded theory. HCPs were interviewed at the Temmy Latner Centre for Palliative Care (TLCPC), a home-based palliative care group of physicians, and 2 hospitals in Toronto, while family members were recruited from TLCPC's records of deceased patients. Six overarching themes, relating to HCP-family relationship dynamics, the experience of loss of relationship, and potential solutions, were derived from the data: (I) home palliative care is intimate; (II) dissatisfaction is experienced with abrupt relationship ending; (III) families benefit from open communication, especially after patient death; (IV) HCPs recognize the insufficiency in bereavement resources; (V) benefits are recognized for a system to ease loss of relationship, and lastly; (VI) challenges with introducing such a system concern HCP. Overall, families and HCPs do not like the loss of relationship post-patient death, and recognize the potential benefits of an approach that would allow for communication going forward.

Survival after Post-Hematopoietic Stem Cell Transplantation AML Relapse: A Single Center Experience

Introduction Post-allogeneic hematopoietic stem cell transplantation (HSCT) acute myeloid leukemia (AML) relapse has a dismal prognosis and no standard of care treatment. Current common treatment options for (re)inducing a graft versus leukemia effect (GvL) are cessation of immunosuppressive therapy, administering hypomethylating agents or high dose chemotherapy. After reinduction of remission is achieved, the effect can be consolidated with a donor lymphocyte infusion (DLI) or a second allogeneic HSCT. In this study we analyzed outcomes of patients with post-allogeneic HSCT AML relapse in our institute. Objectives To evaluate outcome of patients with post-allogeneic HSCT AML relapse, who received different types of reinduction therapy regimens and of whom a subgroup underwent immunological consolidation therapy. Methods Data was collected from the medical history of all 83 adult patients that had received an allogeneic stem cell transplantation for AML or high-risk myelodysplastic syndrome (MDS) at the Amsterdam University Medical Centers between January 1st 2010 and 31st December 2016 and who relapsed before December 31st 2017. In this retrospective analysis, patients were divided into a curative intent treatment group and a palliative care group. Statistical analysis was done with IBM SPSS version 24.0.0.1 using Mann-Whitney U, Chi-square testing, Pearson's R for ordinal variables and Kaplan Meier survival analysis with log rank testing. Results 50 (60%) of the 83 patients were treated with the intent to cure and the other 33 (40%) received palliative care. Of the patients treated with curative intent, 13 (26%) survived. The patients in the palliative care group were older than the patients in the curative intent group (median age 58 vs 53 year, P=0.043). They also had a higher bone marrow blasts count (median 37.5% vs 20.5%, P=0.025), and shorter time between allo HSCT and relapse (median 21 weeks with IQR of 6-28 vs median of 21 weeks with IQR 14-47.25, P=0.047). Within the curative intent group these variables did not differ significantly between survivors and deceased. Of the patients in the curative intent group 44% reached CR and of these patients 50% survived. The majority of the survivors received high dose cytarabine treatment (69%) and immunologic consolidation therapy (69%). A relapse ≤ 12 weeks after allogeneic HSCT but not relapse Conclusion This retrospective analysis of a real-life, non-preselected patient group with post-allogeneic HSCT AML or MDS relapse demonstrated that patients who were fit enough to receive high-dose reinduction therapy, followed by a immunologic consolidation with DLI or a second allogeneic HSCT had the best chance to obtain durable remissions, in particular when immunologic consolidation was performed when the patient had obtained complete remission.

End-of-Life Aspects in a Hematopoietic Stem Cell Transplantation Unit: The Integration of Palliative Care Group in the Transplant Process

Topic Significance & Study Purpose/Background/Rationale Patients submitted to Hematopoietic Stem Cell Transplantation (HSCT) are affected by a burden of symptoms arising from conditioning treatment, clinical complications such infections, bleeding disorders, leading to physical and psychological suffering. The understanding of how hematological patients are managed in the end-of-life may provide improvement in the quality of care since it seems hematological patients have less access to palliative care (PC) when compared to solid tumors. The aim of this study was evaluate the end-of-life scenario of our patients that died after HSCT followed or not by PC team and try to improve the care practice of this patients Methods, Intervention, & Analysis We retrospectively analyzed patients submitted to HSCT who died between January, 2010 and July, 2018 in a single private hospital in Sao Paulo, Brazil. It was recorded cause of death: if TRM (Transplant related Mortality) or relapse/ disease progression (DP) related; the local of death ICU (intensive care unit) or regular room and PC team intervention. For statistical analysis was used Chi-square and likelihood ratio test. Findings & Interpretation A total of 460 patients received HSCT in this period. 345 (75%) adults and 115 (25%) pediatrics. Among them 125 (27,1%) died 101 (80%) adults and 24 (20%) children. In the pediatric population 15 (62.5%) died due TRM and all died in the ICU, PC team followed just one (7%) patient. Nine (37.5%) died due DP, and just one (4%) patient was followed by PC team, and died in regular room free of invasive therapy. In the adult population 55 (54,5%) died due TRM, the PC team followed 10 (18%), of them and; 8 (14.5%) died in ICU. Forty-six (45.5%) of patients died by DP and, 26 patients (56.5%) were followed by PC team, and 16 (35%) died in regular room. Twenty patients were not followed by CP team and 17 (37%) out 20 died in the ICU. In the adult population patients who were followed by PC team have less chance of being transferred to ICU (p Discussion & Implications Our mortality rate is similar to literature, but few patients were followed by PC team. A new practice was established in January 2018 and PC team starts evaluating all adult patients undergoing HSCT. The first visits was in the pre transplant evaluation and then followed by weekly visits during admission period interfering in symptoms management, with this we hope to increase the quality of the assistance offered in the final stage of life. In respect to pediatric patients we are in the process of evaluating our gaps for service implementation. When the PC team is introduced we observed an improved management of patients, family and health team with a decrease of transfers for ICU, giving better quality at the end of life.

A Brief Mindfulness-Based Self-Care Curriculum for an Interprofessional Group of Palliative Care Providers.

Background: Mindfulness-based interventions for health care providers have shown benefits for provider wellbeing and for their patients, but established programs are time-intensive. Objective: To establish the feasibility of a brief mindfulness-based curriculum focused on self-care for an interprofessional group of palliative care providers within the regular workday, and to evaluate the effectiveness of the curriculum in improving the levels of burnout, mindfulness, use of mindfulness meditation practices, and stress levels. Design: Pre-, one-week post-, and seven-month post-intervention survey assessment. The intervention was conducted in five monthly one-hour sessions. Setting: Participants were 29 mixed-professional-background usual-attendees of a monthly educational conference in a well-established palliative care group within an academic medical center. Measurements: Paired, confidential assessments using validated scales (the Five Facet Mindfulness Questionnaire, the Maslach Burnout Inventory, the Ten-item Perceived Stress Scale), report of use of informal and formal mindfulness techniques, narrative data, and satisfaction ratings. Results: Participants reported high satisfaction with the series and showed statistically significant improvements in dimensions of mindfulness and mindfulness practices, sustained for seven months. Burnout levels in this group were much lower than reported national rates; no statistically significant change was seen in burnout over the study period. Narrative data demonstrated retention of curricular content. Conclusions: Delivery of a mindfulness-based self-care series to an interprofessional group of palliative care providers within the regular workday was feasible, well received, and associated with increased mindfulness levels, mindfulness practices, and knowledge.

Process Challenges in Palliative Care for Cancer Patients: A Qualitative Study

Background: Quality assessment and service delivery processes for cancer patients are the major components of palliative care. This study intends to explore stakeholder’s perceptions of palliative care process challenges for cancer patients in Iran.Method: In this qualitative study, we conducted 22 semi-structured interviews from February 2016 to August 2017 in hospitals located in Tehran, Iran. Participants were selected through purposive sampling and included cancer patients, their family caregivers, healthcare providers, and policy-makers. The interviews were analyzed by qualitative directed content analysis based on the Donabedian model. In order to assess the accuracy and validity of the study, we used Lincoln and Guba’s four criteria.Results: After analysis of the interviews, we categorized the codes into a main category, “process”, and three identified subcategories – “weakness of stakeholders’ engagement policies”, “standardized care”, and “applying educational and research approaches”.Conclusion: Palliative care in Iran is a recent discipline. The results have shown that the process of providing services requires the attention of the health system to the standard models for providing palliative care services. In addition, it is necessary to train human resources in generalist and specialist palliative care groups, design palliative medicine curricula, inform general public about cancer, and empower patients and caregivers.

Utilization of palliative care in patients hospitalized with heart failure: A contemporary national perspective.

Despite advances in therapy, heart failure (HF) patients have significant symptom burden and poor quality of life. However, data on palliative care (PC) utilization in this population are scarce. We sought to assess national trends in PC utilization in patients admitted with acute HF. Adults hospitalized with HF without acute coronary syndrome were identified in the National inpatient sample. PC was identified using ICD-9-CM-Code V66.7. Trends in PC utilization, its predictors and its association with length-of-stay and cost were assessed. A total of 939 680 HF patients were hospitalized with HF between 2003 and 2014. Of those,1.2% received PC during the hospitalization, with an upward trend in the use of PC over time (0.12% in 2003 to 3.6% in 2014, P < 0.001). Compared with patients who did not receive PC, those who had PC were older (79 ± 12 vs 69 ± 16 years), and had higher prevalence of Caucasian race (73.4% vs 51.8%), coronary disease (45.6% vs 39.3%), chronic renal disease (79.3% vs 42.8%), and pulmonary hypertension (28.3% vs 15.1%) (P < 0.001). In-hospital mortality (35.2% vs 2.2%), length-of-stay (9 ± 13 days vs 6 ± 6, P < 0.001), cost ($19 984 ± 42 922 vs $11 921 ± 18 175), and non-home discharges (46% vs 19.2%) (P < 0.001) were higher in the PC group. In-hospital mortality in PC group trended downward over time (69% in 2003 vs 29% in 2014, P < 0.001). PC is being utilized in an increasing but overall small number of patients hospitalized with HF. Further research is needed to identify the optimal role and timing of PC in HF patients.

Evaluación prospectiva de la herramienta Palliative Pronostic Score en pacientes con enfermedad oncológica avanzada en manejo con cuidado paliativo de soporte

Objetivo: Evaluar la herramienta Palliative Prognostic Score (PaP Score) en pacientes con cáncer avanzado atendidos en la unidad de cuidados paliativos y dolor en el Instituto Nacional de Cancerología, Bogotá, Colombia. Materiales y métodos: A una muestra de 100 pacientes atendidos por el grupo de Cuidados paliativos, ingresados al área de hospitalización del Instituto Nacional de Cancerología de Bogotá, desde el 13 octubre de 2015, seleccionados consecutivamente, se les aplicó el índice pronóstico de supervivencia PaP Score, para establecer clasificación de supervivencia (grupos A, B y C) a 30 días. Se analizó la supervivencia, usando el método de Kaplan-Meier y el test de log-rank para comparar la distribución de la supervivencia en los tres grupos del PaP Score. Resultados: El PaP Score dividió la muestra de pacientes en tres categorías pronósticas: 15 pacientes en el grupo A (con una probabilidad de supervivencia a un mes mayor del 70%), 36 pacientes en el grupo B (con una probabilidad del 30 al 70%) y 49 pacientes en el grupo C (con una probabilidad menor del 30%). El porcentaje de pacientes vivos a los 30 días estuvo dentro de los límites esperables en cada grupo; así, en el grupo A (probabilidad de supervivencia mayor de 70%) fue de 93,3%, en el grupo B (probabilidad del 30 al 70%) fue 41,7%, y en el grupo C (probabilidad menor de 30%) fue del 8,1%. Conclusiones: El uso del índice PaP Score permite clasificar a los pacientes en tres categorías pronósticas de supervivencia ofreciendo una opción para la estimación clínica de la misma, en pacientes con cáncer avanzado, atendidos en una unidad de cuidados paliativos; esta herramienta es fundamento para que el médico especialista optimice y enfoque los cuidados al final de la vida del paciente y su familia.

Examining the intersection of palliative care, hospice, and concurrent care in Veterans Affairs (VA).

139 Background: The VA advocates for both palliative care and concurrent care (hospice care and cancer-directed treatment). Studies indicate that these policies have increased hospice use and have improved family-reported outcomes and other quality metrics. However, little is known about how palliative care, hospice care and concurrent care may interact to obtain these outcomes. Methods: This was a retrospective cohort study of veterans dying with stage IV non-small cell lung cancer in 2012. VA and Medicare administrative data were used to identify the cohort, chemotherapy and radiation use, hospitalizations, hospice use and length of stay (LOS). Palliative care use was determined by VA data only. Analyses included descriptive statistics, chi-square and analysis of variance. Results: Of the 1763 veterans, 850 (48.2%) received both palliative care and hospice, 392 (22.2%) received hospice only, 241 (13.7%) received palliative care only and 280 (15.9%) received neither. Receipt of cancer-directed treatment or hospitalization in the last 30 days of life was significantly different across these groups (p &lt; 0.0001) and was highest at 65% (182/280) in the neither palliative care or hospice group. In the remaining groups, rates of cancer-directed treatment or hospitalization in the last 30 days were: 39.4% (95/241) in palliative care only, 29.3% (115/392) in hospice only and 23% (198/850) with both palliative care and hospice. Concurrent care was received by 314 veterans (17.8%), 275 also receiving palliative care. Among veterans receiving palliative care and Medicare hospice, concurrent care did not alter hospice utilization rates or LOS: 36.4% (100/275), LOS mean 22.3, median 16.5, range 1-97 and 37.2% (214/575), LOS mean 20.1, median 13, range 1-94, for concurrent care and non-concurrent care respectively. Conclusions: The rates of cancer-directed treatment or hospitalization in the last 30 days of life appeared to be reduced in a continuum from receipt of neither hospice nor palliative care, to receipt of palliative care or hospice alone, followed by receipt of both together. Concurrent care use was facilitated by palliative care without impacting Medicare hospice use or LOS in palliative care recipients.

Cellular phone-based application as a tool in pediatric palliative care.

48 Background: Free cross-platform instant messaging is a popular way of communicating in Panama. Is it possible to apply this in Palliative Care (PC)? Methods: This is a descriptive transversal study of some problems we could solve internally with the help of this cell phone-based application. The universe is the total of consultations of the PC Pediatric Support Team in Panamá Children’s Hospital to the National Program of PC from May 2016 to July 2018. First, we developed a chat group, so all 55 members of the national palliative program can share specific information related to PC topics. We describe the most common problems that we can solve with the help of instant messaging technology such as: 1. Presentation of cases at the time of their going-back home from the hospital-team to the community-team. 2. Presentation of urgent cases to the National Aero-Naval Force to be transported by boat or plane. 3. Education of mothers on specific problems they have at home. Results: We had 113 consultations in pediatric palliative care group. Of those, 78% had to be presented to the community-health-care-center (88 cases). The time-of-response was in the range of 5-120 minutes. We had to arrange sanitary transportation by boat or plane in 14% of the cases. Of those cases we obtained a response by the Aero-Naval force in less than 24 hours. We solved specific palliative symptom problems such as: fever, administration of the rescue dose, mucositis, and coping problems in some patients that lived more than two hours from the nearest health-center. For this we used educational videos made for this purpose. Conclusions: Instant messaging technology is used for the provision of palliative care communication, safety transportation and clinical problem solving. It had to be used in conditions that protect the privacy of patients and families. This current study suggest that this is a new opportunity that must be considered for its efficiency in solving specific problems.

Psychotherapy for depression among incurable cancer patients

The most common psychiatric diagnosis among cancer patients is depression; this diagnosis is even more common among patients with advanced cancer. Psychotherapy is a patient-preferred and promising strategy for treating depression among cancer patients. Several systematic reviews have investigated the effectiveness of psychological treatment for depression among cancer patients. However, the findings are conflicting, and no review has focused on depression among patients with incurable cancer. To investigate the effects of psychotherapy for treating depression among patients with advanced cancer by conducting a systematic review of randomized controlled trials (RCTs). We searched the Cochrane Pain, Palliative and Supportive Care Group Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and PsycINFO databases in September 2005. All relevant RCTs comparing any kind of psychotherapy with conventional treatment for adult patients with advanced cancer were eligible for inclusion. Two independent review authors identified relevant studies. Two review authors independently extracted data from the original reports using standardized data extraction forms. Two independent review authors also assessed the methodological quality of the selected studies according to the recommendations of a previous systematic review of psychological therapies for cancer patients that utilized ten internal validity indicators. The primary outcome was the standardized mean difference (SMD) of change between the baseline and immediate post-treatment scores. We identified a total of ten RCTs (total of 780 participants); data from six studies were used for meta-analyses (292 patients in the psychotherapy arm and 225 patients in the control arm). Among these six studies, four studies used supportive psychotherapy, one adopted cognitive behavioural therapy, and one adopted problem-solving therapy. When compared with treatment as usual, psychotherapy was associated with a significant decrease in depression score (SMD = -0.44, 95% confidence interval [CI] = -0.08 to -0.80). None of the studies focused on patients with clinically diagnosed depression. Evidence from RCTs of moderate quality suggest that psychotherapy is useful for treating depressive states in advanced cancer patients. However, no evidence supports the effectiveness of psychotherapy for patients with clinically diagnosed depression.

Palliative care and end-of-life health care utilization in elderly patients with pancreatic cancer.

Palliative care has been associated with improved survival and quality of life, with lower rate of end-of-life health care utilization and cost. We examined trends in palliative care utilization in older pancreatic cancer patients. Pancreatic cancer patients with and without palliative care consults were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database between 2000 and 2009. Trend of palliative care use was studied. Emergency room/intensive care unit (ICU) utilization and costs in the last 30 days of life were compared between both groups using propensity score-matched (PSM) analysis. Of the 54,130 patients, 3,166 (5.8%) received palliative care and 70% received it in the last 30 days of life. The proportion of patients receiving palliative care increased from 1.4% in 2000 to 7.4% in 2009 (P<0.001). Patients with palliative care were more likely to be older, Asian and women. In the unmatched and PSM population, the average visits to the ER in the last 30 days of life were significantly higher for patients who received palliative care, and had a significantly higher cost of care. Similarly, ICU length of stay in the last 30 days of life was higher in patients who did not receive palliative care in both PSM and unmatched patients. Cost of care and number of ICU admissions were not different between palliative and non-palliative care groups in PSM and unmatched patients. In this study of Medicare patients with pancreatic cancer, palliative care use has increased between 2000 and 2009. Palliative care was largely offered close to the end of life and was not associated with reduced health care utilization or cost.

Clinical and laboratory characteristics associated with referral of hospitalized elderly to palliative care.

ABSTRACTObjectiveTo investigate clinical and laboratory characteristics associated with referral of acutely ill older adults to exclusive palliative care.MethodsA retrospective cohort study based on 572 admissions of acutely ill patients aged 60 years or over to a university hospital located in São Paulo, Brazil, from 2009 to 2013. The primary outcome was the clinical indication for exclusive palliative care. Comprehensive geriatric assessments were used to measure target predictors, such as sociodemographic, clinical, cognitive, functional and laboratory data. Stepwise logistic regression was used to identify independent predictors of palliative care.ResultsExclusive palliative care was indicated in 152 (27%) cases. In the palliative care group, in-hospital mortality and 12 month cumulative mortality amounted to 50% and 66%, respectively. Major conditions prompting referral to palliative care were advanced dementia (45%), cancer (38%), congestive heart failure (25%), stage IV and V renal dysfunction (24%), chronic obstructive pulmonary disease (8%) and cirrhosis (4%). Major complications observed in the palliative care group included delirium (p<0.001), infections (p<0.001) and pressure ulcers (p<0.001). Following multivariate analysis, male sex (OR=2.12; 95%CI: 1.32-3.40), cancer (OR=7.36; 95%CI: 4.26-13.03), advanced dementia (OR=12.6; 95%CI: 7.5-21.2), and albumin levels (OR=0.25; 95%CI: 0.17-0.38) were identified as independent predictors of referral to exclusive palliative care.ConclusionAdvanced dementia and cancer were the major clinical conditions associated with referral of hospitalized older adults to exclusive palliative care. High short-term mortality suggests prognosis should be better assessed and discussed with patients and families in primary care settings.