Palliative Care Patients Research Articles

Access to palliative care in patients with multiple myeloma in the USA: A National Cancer Database (NCDB) analysis of years 2004-2020.

7563 Background: Palliative care (PC) can improve the quality of life for patients with multiple myeloma (MM). Despite its recognized importance, research gaps persist in understanding factors influencing PC accessibility and utilization, particularly in the diverse MM patient landscape in the real-world setting. This study explores potential associations between race, ethnicity, socioeconomic factors, and PC access for MM patients in the USA. Methods: Utilizing the NCDB, we identified 202,949 MM patients diagnosed from 2004 to 2020. Multivariate logistic regression analysis was conducted with SAS version 9.4, to determine independent factors predicting PC access. Results: Analysis of 202,949 MM patients revealed notable disparities for access to PC. Female patients exhibited lower PC odds (OR: 0.94, p < 0.0001) compared to male patients, as did Black patients (OR: 0.80, p < 0.0001) and other racial groups (OR: 0.84, p < 0.0001) compared to White patients. Hispanic ethnicity was associated with lower PC utilization odds (OR: 0.84, p < 0.0001) compared to non-Hispanics. Earlier years (2004-2007) showed higher PC odds (OR: 1.12, p < 0.0001), while subsequent years (2008-2011, 2012-2015) exhibited lower odds (OR: 0.93, p = 0.0009; OR: 0.87, p < 0.0001, respectively) compared to the most recent years (2016-2020). Academic settings had lower PC odds than non-academic facilities (OR: 0.78, p < 0.0001). Insurance status varied, with no insurance (OR: 1.40, p < 0.0001), Medicaid (OR: 1.17, p < 0.0001), and other government insurance (OR: 1.38, p < 0.0001) linked to higher PC odds compared to private insurance. Lower annual household incomes (<$38,000, $38,000-$47,999, $48,000-$62,999) had increased PC odds compared to higher incomes (>$63,000) (all p < 0.0001). Areas with a higher percentage of individuals without a high school degree exhibited lower PC odds, notably 21% (OR: 0.83, p < 0.0001) and 13.0%-20.9% (OR: 0.94, p = 0.0222) compared to <7.0% without a high school degree. Greater distance (>30 miles) reduced PC odds compared to shorter distance (<10 miles) to treatment facility (OR: 0.83, p < 0.0001). A Charlson-Deyo score of 1 increased PC odds compared to a score of 0 (OR: 1.12, p < 0.0001). Conclusions: Our real-world analysis reveals substantial disparities in MM patients’ PC access and utilization. Female patients and minority groups (Blacks and Hispanics) face significant challenges. The dynamic trends over time and socioeconomic impacts underscore the need for integrating PC and targeted interventions for overall MM patient well-being. Our findings pave grounds for future prospective studies.

Examining emerging trends in palliative care utilization for malignant neoplasms with the highest mortality rates.

e24066 Background: Lung, colorectal, pancreatic, breast & prostate cancer account for the top 5 malignancies resulting in mortality in the US. The need for palliative care in patients with these malignancies continues to grow & monitoring its utilization is crucial, especially among different racial groups & ethnicities. Methods: In this study, the TriNetX database which is a collaboration between; pharmaceutical companies, research organizations & HCOs was used. A total of 3,221,731 de-identified pts (pediatric, AYA & adult) was analyzed. The impact of palliative care use vs absence between 2009-2023 was compared in 4-year cohorts, with univariate & multivariate analyses. A p-value < 0.05 was deemed significant. Chi-square was employed to assess palliative care utilization or absence through the years for each group. Results: Analyzing Table 1, palliative care utilization was greater among Non-Hispanics and Whites, as evidenced by the mean. White pts consistently exhibit a higher use compared to other racial groups, but it declined between 2019-2023. The lowest use of palliative care was among Native Hawaiians, Native Americans, & Asians. Black, Latino, Other race, Unknown Race & unknown ethnicity pts accounted for about 50% of its use. Similarly, in most racial & ethnic groups a decline in its non-utilization was observed progressively. Based on the chi-square test, overall results show a significant P-value for all racial & ethnic groups through the years, except for white pts with a p-value of 0.1847. Conclusions: The study highlights disparities that exist in palliative care utilization among racial & ethnic groups. Despite increasing trend in its use, its utilization remains constant among minorities. These details are pivotal in advancing an inclusive healthcare that enhances end of life outcomes for all patients. [Table: see text]

Trends in palliative care utilization among patients with ovarian cancer in the United States.

e24083 Background: Palliative care is a resource that is utilized for patients with serious illnesses to focus on symptom management, quality of life, and goals of care for patients and their families. It can be initiated at any point in illness course with benefit beginning as early as the time of diagnosis. This study's objective is to evaluate trends in inpatient palliative care utilization and associated factors in patients with ovarian cancer. Methods: We performed a retrospective cohort study using the National Inpatient Sample (NIS) from 2010-2020. Patients with ovarian, fallopian tube, and primary peritoneal cancer and palliative care (PC) utilization were identified using ICD-10 codes. Chi square and t tests were used to evaluate differences between patients who received PC versus patients who did not. Multivariate and multinomial logistic regression was utilized to determine factors associated with PC use. Results: A total of 479,169 patients with a diagnosis of ovarian cancer were included, of which 58,970 (12.3%) utilized inpatient PC. Between 2010 and 2020, there was a significant upwards trend in PC usage in patients hospitalized with a diagnosis of ovarian cancer from 6.9% to 18.1%. Median age of patients using PC was 67 compared to 65 among those not using PC (p < 0.001). PC utilization was more prevalent among patients with a diagnosis of depression (8.7% v 6.4%; p < 0.001), Black race (12.4% v 10.3%; p < 0.001), in urban environments (94.0% v 92.2%; p < 0.001), and those at hospitals designated as teaching status (72.4% v 66.8%; p < 0.001). In a multivariate regression analysis, the odds of palliative care utilization were 1.59times higher (p < 0.001) for patients with moderate loss of function compared to patients with minor loss of function. Patients with hospital stays 0-3 days were more likely to utilize palliative care compared to 4-7 days (p < 0.001) Multinomial logistic regression for disposition among patients using palliative care to additional care versus routine care was 1.59 times higher in patients with 8+ days hospital stay compared to 4-7 days. For those with shorter stays of 1-3 days versus 4-7 days patients were 1.65 times more likely to die versus routine care. Conclusions: The use of inpatient PC for patients with ovarian cancer increased over time. Palliative care utilization was associated with older age, Black race, depression, and treatment in urban environments or in teaching hospitals. The utilization of inpatient palliative care was higher in patients with more extreme losses of function. These patients were more likely to have shorter lengths of stay due to a higher disposition of death over routine care. Given these findings, patients receiving palliative care may be sicker and closer to the end of life than those who do not. Although there have been higher rates of inpatient palliative care over time, there is still room for earlier implementation.

Evolution of quality of life (QoL) and symptom burden (SB) in patients receiving inpatient palliative care (PC) following one week of care in a specialized palliative care unit (PCU): A comparison of two groups, with one receiving specialized outpatient palliative care prior to admission.

e23160 Background: This study sought to investigate changes in QoL and SB among PC Pt undergoing one week of inpatient care in a specialized PCU. The Pt population was stratified into two groups (Gp), with one Gp pretreated from pre-admission PC provided by an outpatient multidisciplinary PC team, while the other Gp did not receive such support prior to admission. Although the average duration of treatment at a PCU in Germany is 1-2 weeks, the question also arises as to whether a significant improvement in SB/QoL can be expected after just one week of PC in a PCU. Methods: PC Pt with various cancer entities were prospectively included in a non-randomized study. Pt in Gp 1 received outpatient specialized PC prior to admission, while Pt in Gp 2 did not. Over an 8-month period, we gathered data from one academic cancer center, utilizing the EORTC QLQ-C30, one of the most widely used Pt reported outcome (PRO) instruments to assess health-related QoL in cancer Pt. Pt completed the QLQ-C30 at T0 (admission) and T1 (day 7), enabling the assessment of potential changes in their QoL and SB over time. Results: A total of 103 pt (51.5% male) were enrolled (Gr 1: 42%, Gr 2: 58%). At T0, there were no significant differences regarding QLQ-C30 scores between Gp 1 and 2. Over the course of one week several significant and clinically relevant changes in QoL and SB were found: Emotional functioning demonstrated an uplift in both Gp (Gp 1: mean (M) 41.5 IQR 33 vs. 53.1 IQR 50, p 0.014, Gp 2: M 48.2 IQR 46 vs. 56.8 IQR 58, p 0.029), as did the global health status (Gp 1: M 20.7 IQR 17 vs. 36.2 IQR 33, p < 0.001, Gp 2: M 25.6 IQR 25 vs. 35.3 IQR 33, p < 0.001). Nausea and vomiting showed a reduction (Gp 1: M 29.9 IQR 17 vs. 6.8 IQR 0, p < 0.001, Gp 2: M 22.6 IQR 17 vs. 8.2 IQR 0, p < 0.001), along with a notable decline in pain (Gp 1: M 67.4 IQR 67 vs. 25.3 IQR 17, p < 0.001, Gp 2: M 73.1 IQR 83 vs. 29.7 IQR 17, p < 0.001). A decrease was observed in insomnia (Gp 1: M 63.6 IQR 67 vs. 27.6 IQR 33, p < 0.001, Gp 2: M 60.1 IQR 67 vs. 27.6 IQR 33, p < 0.001). There were no significant differences between Gp 1 and 2 in the extent of improvement in the various symptom scales from T0 to T1, except for cognitive functioning, where Gp 1 exhibited an increase while Gp 2 demonstrated a decrease (p 0.044). Conclusions: The findings of our study demonstrate that QoL and several symptoms prevalent in cancer Pt cared for in the PCU experienced significant enhancement over the span of just one week of PCU care. Both Gp, Pt receiving specialized outpatient PC prior to admission and those without, equally benefited from inpatient PC. All mentioned changes from T0 to T1 are considered not only significant, but clinically relevant.

Can systematic dental examinations or treatments in addition to routine multidisciplinary treatment in a palliative care unit (PCU) improve the quality of life (QoL) and symptom burden (SB) of patients (Pt) receiving palliative care (PC)?

e23163 Background: Pt with advanced cancer who require PC often experience not only common symptoms such as pain, shortness of breath, or nausea, but also oral health and dental problems. In many PC teams, and even in dedicated PCUs, the inclusion of dentists in the Pt care team is rare, resulting in a lack of routine dental screening or treatment. Objectives:To investigate the extent to which Pt admitted to a PCU suffer from oral health or dental problems and to explore the impact of incorporating dentists into inpatient PC, with a focus on improving QoL and reducing SB. Methods: In this monocentric study, data were collected in one PCU over a period of eight months. At admission, T0, Pt underwent both a dental examination and interviews using established questionnaires, the EORTC QLQ-C30 (core, general) and OH 15 (oral health). One week later, at T1, Pt underwent a follow-up examination and interview. The QLQ-C30 is a widely accepted instrument developed to assess health-related QoL in cancer Pt. Results: A total of n = 103 Pt (48.5% women) were enrolled. The median time since the last dental visit was 1 year. The dental status at T0 was worse (Table 1). At T1, statistically and clinically significant changes in oral QoL and SB were observed. Notable changes were observed in OH-QoL score (mean 60.60 vs. 88.40, p < 0.001), sticky saliva (mean 38.10 vs. 11.28, p < 0.001), sensitivity to food and drink (mean 35.25 vs. 8.16, p < 0.001), sore mouth (mean 23.87 vs. 4.98, p > 0.001), and poorly fitting dentures (mean 38.63 vs. 8.07, p < 0.001). Improvements in xerostomia, candidiasis and mucositis were also observed. A confidential survey was administered to both Pt and palliative care staff to assess their satisfaction with the addition of systematic dental care to routine multidisciplinary PC. 97% of respondents indicated a high level of satisfaction with this treatment program. Conclusions: The study underscores the powerful contribution of integrating a dentist into the PC, e.g. in a PCU, resulting in a notable reduction in oral symptom burden. This contributes to improved care status, alleviation of distressing symptoms and ultimately an improvement in QoL. The results strongly support the consideration of dental support (e.g. routine dental screening) as an integral part of PC. [Table: see text]

Factors associated with the receipt of palliative care in Native American patients with hepatocellular carcinoma: A retrospective analysis.

e16202 Background: Hepatocellular Carcinoma (HCC) is a leading cause of cancer-related deaths in the United States. This primary liver malignancy often has a poor prognosis and commonly metastasizes to the lungs, lymph nodes, bones, and adrenal glands. HCC has a high burden of disease with many patients suffering from discomfort and pain related to the disease and its treatment. Palliative care is a unique form of specialized care that provides relief, increasing comfort, and quality of life to patients suffering from illness. Many studies note its effectiveness in helping patients at any point in their illness. Furthermore, recent studies have shown that Native Americans face barriers to receiving palliative and end of life care. Thus, this study aims to examine the factors associated with receipt of palliative care within Native American HCC patients. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with Hepatocellular Carcinoma from 2004 to 2019 using the histology code 8170 and race code 03 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, ANOVA Chi-Square, and Cox Proportional Hazards tests were performed. Data was analyzed using SPSS version 28 and statistical significance was set at α = 0.05. Results: Out of 1536 Native American patients with HCC, 92 (5.9%) received palliative care. Patients who received palliative care experienced shorter mean survival than those who did not receive palliative care (15 vs 42 months; p < 0.001). After controlling for age, year of diagnosis, surgical status and adjuvant therapies, not receiving palliative care was associated with an independent decrease in hazard (HR = 0.625, p < 0.05). Palliative care patients were more likely to present with stage III and IV HCC, experience a longer delay in receiving treatment (69 vs 48 days) and have bone and lung metastasis when compared to those who did not receive palliative care (p < 0.05). Patients who did not receive palliative care were more likely to have Medicare or Medicaid for insurance (p < 0.05). There were no significant differences in the age, income bracket, facility type, tumor size or time to surgery between the patients who received palliative care and those who did not. Conclusions: This study found that patients with HCC are more likely to utilize palliative care if they have severe disease that metastasized to other organ systems. There is a higher mortality among patients who receive palliative care most likely because they had more severe disease. This research demonstrates the common trend of HCC patients underutilizing palliative care in the early stages of disease. Exploring the impacts early palliative care can have on HCC patients’ survival and quality of life would be valuable future areas of research.

Effect of CBD on anti-tumor immune response and interaction with GPR55 on MAPK signaling in head and neck squamous cell carcinoma.

6060 Background: Head and neck squamous cell carcinoma (HNSCC) is a lethal malignancy and comprises two distinct etiology: human papillomavirus (HPV)+ve and -ve. Marijuana use is associated with HPV+ oropharyngeal infection and conflicting data show positive and negative associations of daily marijuana use with HPV+ and tobacco-associated HPV- HNSCC. However, cannabinoid use continues to increase in the US general population for recreational purposes as well as in cancer patients for palliative care. G-protein coupled receptors (GPCRs), including cannabinoid GPCRs, stimulated by specific ligands interact with multiple G proteins creating diversity and complexity of signaling. In this study, we aimed to investigate the CBD-induced GPCR coupling and its effect on anti-tumor activity by modulating immune response in HNSCC by using pre-clinical models. Methods: The anti-cancer effect of CBD was measured by cell proliferation, apoptosis and migration analysis. Next, TGF-α shedding assay was performed to identify the CBD-induced GPCR coupling with different cannabinoid receptors. The cannabinoid receptor GPR55 was subjected to silencing by siRNA and western blot analysis was performed to evaluate its role in activation of p38 MPAK pathway. Next, the anti-tumor immune response of CBD was evaluated by using an immunocompetent syngeneic C57BL/6 mEER RasG12D+/- HPV E6/E7 transformed tongue epithelial cell model that serves as a model for HPV+ HNSCC and the 4MOSC1 orthotopic, syngeneic, 4NQO (4-nitroquinoline-1 oxide)-induced murine oral tongue squamous cell carcinoma C57BL/6 mouse model that serve as HPV- HNSCC model as well as in immune-deficient Rag1 -/- and athymic nude mouse followed by measurement of immune cell infiltration by IHC analysis. Results: We found that 10μM of CBD treatment inhibited cell proliferation and migration in HNSCC cells by promoting apoptosis. Interestingly, we observed that CBD resulted in GPCR coupling for Gαi with GPR55 and Gαq/o and Gαq/s for CNR1, CNR2 and GPR55. Furthermore, we silenced GPR55 and observed that 10μM of CBD treatment inhibits the activation of p38 MAPK pathway whereas it promotes activation in non-silenced HNSCC cells. Next, we observed that treatment with 10μM of CBD significantly inhibited tumor growth compared to control in both HPV- and HPV+ models in immune-intact animals whereas, no significant difference in the tumor growth was observed in immune-deficient (Rag1 -/- and athymic nude) mouse, indicating role of CBD in modulating tumor immune microenvironment. We also observed CBD treatment enhanced CD4+ and CD8+ T cell infiltration into the primary tumors of HPV+ and HPV- mice models, implicating a downstream cytotoxic T cell response. Conclusions: Our study suggests that CBD promotes anti-tumor activity by modulating the immune microenvironment and interacts with GPR55 to activate intrinsic MAPK signaling pathway.

Impact of COVID-19 on referrals to outpatient palliative care for patients with advanced cancer in a safety-net health system.

e24071 Background: Medically underserved adults with cancer experience challenges with access to care and tend to present at later disease stage. Amidst the complex needs of safety-net patients, the value of early palliative care (PC) services can go unrecognized. Few studies have examined PC referral patterns in the outpatient setting among advanced cancer patients within a safety-net system, and none has studied how or whether referrals have evolved since the most acute stages of the COVID-19 pandemic. This study examined PC referrals for cancer patients seen as outpatients in the urban safety-net primary provider of cancer care for uninsured individuals in Dallas, TX, and assessed changes from before to after the acute pandemic phase. Methods: We used tumor registry records linked to outpatient PC referral data from the safety-net health system’s electronic health record from January 1, 2018 to July 31, 2023. The primary outcome was a binary indicator for receipt of PC referral among patients diagnosed with advanced-stage solid tumor cancer. Using a multivariate logistic regression model, we evaluated whether our independent variable – a binary indicator for pre-pandemic (January 1, 2018 to February 28, 2020) and post-pandemic (March 1, 2020 to July 31, 2023) time periods – was associated with PC referrals. We included age, sex, race/ethnicity, cancer type, preferred language, and insurance as covariates. Results: Among 1,590 eligible patients (mean age 58.1, range: 21-94), 44% were female and 75% were non-White. Diagnoses included lung (20%), gastrointestinal (17%), colorectal (14%), breast (9%), prostate (9%), head/neck (9%), pancreatic (8%), gynecologic (6%), and other (8%) cancers. Across both time periods, a total of 785 (49%) of patients received a PC referral. Whereas 53% of the 754 patients in the pre-pandemic cohort received a PC referral, 46% of the 836 in the post-pandemic cohort received a referral. In the adjusted regression model, pre-pandemic patients were 1.26 times more likely to have a PC referral than post-pandemic patients (95% CI, 1.02-1.56). Referrals varied by cancer type across both time periods – compared to breast cancer patients, gynecologic cancer patients had lower odds of PC referral (aOR, 0.19; 95% CI, 0.10-0.36) and pancreatic cancer patients had higher odds of PC referral (aOR, 2.93; 95% CI, 1.71-5.00). Conclusions: Our analysis showed that referrals declined during the COVID-19 pandemic and revealed differing underlying patterns of PC referral along disease groups. Understanding pre-existing referral patterns and lasting practice changes post-pandemic can support clinicians to integrate PC and improve cancer outcomes. Findings can be used to develop interventions, such as clinical triggers, to improve PC delivery for underserved cancer patients.

Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers.

Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.

Feasibility of Weekly Integrated Palliative Care Outcome Scale (IPOS) Within a Stepped Care Model

ContextPatients with advanced cancer may experience symptoms and concerns that are inadequately identified by the healthcare team, leading to calls for patient-reported symptom monitoring. ObjectivesAssess the feasibility of administering weekly patient-reported online Integrated Palliative care Outcome Scale (IPOS) questionnaires within the context of a stepped care model in the outpatient care setting. MethodsAnalysis of intervention group data in a randomized controlled trial to assess the effectiveness of a stepped care model of palliative care for patients with advanced cancer. Patients in the intervention group were invited to complete the IPOS weekly for 16 weeks through a remotely-administered online questionnaire. At the end of the 16-week period, patients were invited to complete a feedback survey. Multivariable logistic regression was used to assess factors associated with more versus less than 70% completion of weekly questionnaires. ResultsAmong 111 patients who survived more than 16 weeks, the mean number of questionnaires completed was 9.2/16 (58%). A total of 53 out of the 111 patients (48%) completed more than 70% of the questionnaires. Higher education level was found to be associated with higher completion of the questionnaires. A total of 79 out of 111 (71%) patients responded to the feedback survey, of which 67 (85%) felt comfortable with completing the online questionnaire and 11 (14%) felt it was troublesome to complete it on a weekly basis. ConclusionIn our study, there was suboptimal completion of patient-reported IPOS questionnaire. Further research is needed to improve the uptake of patient-reported outcomes in real-world clinical settings.

Technology-enhanced palliative care for patients with advanced cancer undergoing phase I therapies: A pilot randomized clinical trial (RCT).

12017 Background: Outpatient palliative care (PC) has been found to improve quality of life (QOL). It is not known if more frequent symptom monitoring and PC nursing contacts between clinic visits would offer additional benefits. We conducted a pilot RCT to examine the effect of a specialist PC referral with and without technology-enhancement (TEC) on symptoms in patients undergoing Phase I cancer therapies. Methods: This single-center parallel group RCT enrolled adult patients with advanced solid tumors prior to starting Phase I therapies and at least 1 Edmonton Symptom Assessment Scale (ESAS) symptom ≥4/10 and ESAS Global Distress Score (GDS) ≥20/90. Patients were randomized to PC alone or PC + TEC in a 1:1 ratio. Over the 12 w period, the PC group had in person or virtual outpatient visits with a PC physician, nurse, and as needed psychotherapist every 4 weeks; the PC + TEC group also received weekly symptom monitoring with ESAS electronically and weekly nursing phone call. The primary outcome was within-group change of GDS from baseline to 2 w; secondary outcomes included change in GDS over 4, 8, and 12 w, and change in QOL (FACIT-Sp) over 2, 4, 8 and 12 w. We estimated that a sample size of 50 patients per group would provide 90% power to detect a within-group GDS difference of 6 units with a 2-sided α of 2.5% and 20% attrition. Results: Between 12/15/2020 and 12/21/2022, 115 patients were enrolled and 101 were randomized (PC + TEC n = 57, PC n = 44). By 2 w, PC + TEC showed a significant within-group improvement in GDS (mean change -5 [95% CI -8.9, -1.2]; P= 0.01) but not PC alone (Table). PC+TEC group also had a significant improvement in GDS at 8 w and 12 w and in FACIT-SP at 2 w, 8 w and 12 w. PC alone group had a significant within-group improvement in GDS at 4 w and 12 w but no significant differences in QOL were detected. This study was not powered for between group comparison; however, FACIT-SP at 12 w was significantly higher in PC+TEC vs. PC alone (Table; mean difference 13.9; P= 0.02). Conclusions: Higher intensity of PC with closer monitoring showed within-group improvement in symptoms and QOL, while PC alone had some symptom reduction but no QOL improvement. Further studies are needed to confirm the QOL benefit of PC + TEC over PC alone. Clinical trial information: NCT04989556 . [Table: see text]

Oncologic outpatient specialty palliative care referral utilization: A single institution quality improvement project.

e23205 Background: ASCO recommends that late-stage and/or recurrent disease patients with a prognosis of 6-24 months receive specialty palliative care within eight weeks of diagnosis. Prior studies suggest only 30% of eligible patients are referred to outpatient palliative care. Little is known about existing referral patterns to direct quality improvement initiatives. Our aim was to characterize outpatient palliative care referral sources, timeliness, and completion rates across our cancer center. More broadly, this investigation may serve as a model for outpatient palliative care utilization improvement at other cancer centers. Methods: A single institution retrospective quality improvement study was conducted of patients in the seven oncology subspecialties with the most palliative care referrals from 2019 – 2022. Data collected included demographics, referral source, and utilization metrics. Outcomes were rate of referral completion and time from referral to first palliative care visit, hospice enrollment, and/or death. Descriptive statistics were performed. Results: 1671 outpatient specialty palliative care referrals were placed. 57% were initiated by medical oncologists, 21% by inpatient palliative care consulting service at hospital discharge, and 14% by surgical oncology. 27% of referred patients did not schedule an appointment. Gynecologic and breast cancer patients had the highest rates of being scheduled. Median time from referral to appointment was 20 days (interquartile range 9 – 30 days). Reasons patients did not utilize palliative care included transition to hospice (41%), lack of interest (41%), or death prior to visit (7%). 79% of patients seen by palliative care who died were enrolled in hospice. Median time from palliative care referral to hospice enrollment was 66 days (IQR 22 – 164 days), and median time from hospice enrollment to death was 13 days (IQR 5 – 31 days). Conclusions: In a single institution self-evaluation, most patients referred to outpatient specialty palliative care completed referral within thirty days. Within the context of this institution, relevant goals for quality improvement interventions include increasing palliative care referrals among surgical oncologists and shifting palliative care referrals earlier in the disease course and prior to need for inpatient hospital admission. Understanding the elements of the creation of our palliative care referral database and relevant data tracking may serve as a method for other institutions to target interventions that may improve uptake of outpatient palliative care referrals at cancer centers more broadly.

Audit of an in-patient palliative care quality improvement process for patients with pancreatic ductal adenocarcinoma in a South African teaching hospital

Audit of an in-patient palliative care quality improvement process for patients with pancreatic ductal adenocarcinoma in a South African teaching hospital

Quality of Care during the COVID-19 Pandemic: A Qualitative Exploration of Bereaved Caregivers' Experiences at a Hospice Residence.

Background: An essential component of residential hospice care is the provision of high quality palliative care. The perspectives of quality of care from palliative care patients and bereaved caregivers have increasingly been studied to guide quality improvements. Aim: The study aimed to explore the experiences and perceptions of bereaved caregivers of patients who died in residential hospice during the coronavirus disease-19 (COVID-19) pandemic to determine perceptions of quality of care, caregiver grief and bereavement, and the impact of the COVID-19 pandemic. Design: Qualitative exploratory study using secure, web-based semistructured interviews. Data were analyzed using thematic analysis. Setting/Participants: A total of 15 bereaved caregiver participants were recruited from two residential hospice sites in Ottawa, Ontario. Results: Participants identified several factors that impacted the quality of care in residential hospice, including the impact of the COVID-19 pandemic itself. The findings are presented in three main themes: (1) quality of residential hospice end-of-life care; (2) caregiver perceptions of their grief and bereavement; and (3) impact of the COVID-19 pandemic on hospice quality of care and caregiver bereavement. Conclusions: The COVID-19 pandemic had a significant impact on the patient and caregivers experience of hospice, including perception of quality of care and caregiver experience of grief and bereavement.

Palliative Care Needs of Patients with Musculoskeletal Malignancies.

This review aims to assess the literature regarding current treatment options for the palliative care of patients with advanced musculoskeletal malignancies whether primary or metastatic. The inclusion of specialized palliative care physicians, in conjunction with surgeons, medical oncologists, radiation oncologists, interventional radiologists, and mental health professionals, results in better control of end-of-life symptoms in both children and adults with terminal musculoskeletal malignancies. The palliative care of patients with musculoskeletal malignancies requires a multi-disciplinary team and benefits from specialized palliative care physicians. The unique impacts of musculoskeletal malignancies on ambulation and independence creates additional mental and physical burdens on patients and care-takers alike. Palliative care should focus on preserving ambulatory function and patient independence, in addition to managing chronic pain and other end-of-life symptoms common to these malignancies.

Embodiment of Pharmacist Intervention in Palliative Care and Augmentation of a Curriculum for its Assessment

Background Palliative care is the care of patients who have progressive, life-threatening illnesses and who are facing death in the foreseeable future. Since there is a growing need for pharmacist’s intervention in palliative care and there is a gap in the education of palliative care for pharmacy students, this study aims to identify roles and services that have to be performed by palliative care pharmacists in medication-related areas and also to formulate an add-on course to train pharmacy graduates. Materials and Methods A prospective interventional study was done in the palliative care centre in Perinthalmanna, Kerala, India. Relevant data were pooled and analysed for drug-related problems. Necessary interventions were made. Results were interpreted and an add-on course for the training of pharmacy graduates was formulated. Results A total of 88 patients were included in the study. The most prevalent conditions in our palliative setting were kidney disease, liver disease, cancer and stroke. Notably, 38 and 10 cases were found to have drug interactions and drug duplications, respectively. Four patients required dosage adjustments. Fifty cases involved pharmacist intervention which improved the outcome by 80%. At the end of the study, a curriculum was formulated to implement a 3-month add-on course entitled ‘PALLIATIVE PHARMACY’ under the guidance of an Expert committee for training pharmacists and pharmacy students. Conclusion The study identified that there are various roles a pharmacist must undertake in a palliative setup. The involvement of pharmacists in patients’ treatment helps to prevent drug-related problems to a greater extent. The addition of an integrated course for the management of palliative care patients will help to improve the learning as well as practical skills of pharmacists. Incorporating basic and clinical sciences in the therapeutic course is an effective learning plan.

Nutritional Status as a Prognostic Factor for Survival in Palliative Care: A Retrospective Observational Analysis of Home Parenteral Nutrition in Cancer Patients with Inoperable Malignant Bowel Obstruction.

Palliative care patients with malignant bowel obstruction are particularly at risk of developing malnutrition, which in turn directly shortens survival time and worsens quality of life (QoL). According to the available data, the survival time in this patient group is often less than three months. To avoid further complications related to malnutrition and poor outcomes in oncological therapy, nutritional therapy such as home parenteral nutrition (HPN) is offered. The aim of this study was to investigate whether nutritional status is a prognostic factor for survival in palliative care patients with malignant inoperable bowel obstruction qualified for home parenteral nutrition and which nutritional assessment tool has the most accurate prognostic value. This retrospective observational analysis included 200 patients with malignant bowel obstruction referred for home parenteral nutrition between January 2018 and August 2023. The analysis included laboratory test results, body mass index (BMI), Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI) and malnutrition as defined by the Global Leadership Initiative on Malnutrition (GLIM). The average survival time of the patients was 75 days. Patients with higher NRI and PNI scores were more likely to survive (NRI: p < 0.001; PNI: p < 0.001). The GLIM criteria, SGA scores and BMI values did not prove to be good prognostic factors for survival (GLIM p = 0.922, SGA p = 0.083, BMI p = 0.092). The results suggest that the use of NRI and PNI may be helpful in prognosing survival in these patients and that prevention of the development of malnutrition through earlier nutritional assessment and intervention should be considered in this patient group.

Challenges and solutions of conducting dementia clinical trials: A palliative care at home pilot for persons with dementia.

Recruitment and retention are common challenges in clinical trials, particularly with older adults and their caregivers who often benefit from palliative care but have significant strain from caregiving. In recent years, there has been an expansion in home-based palliative care programs, especially for patients with dementia. Because these programs often rely on physicians or advanced practice nurses, they are quite costly and may be difficult to staff due to workforce shortages. We created a novel program of home-based palliative care for patients with advanced dementia and their families, which centers around a community health worker, a social worker, and a nurse. We report on challenges our trial encountered and corresponding solutions. We enrolled 30 patients and their 30 caregivers in our pilot trial of home-based palliative care. We found two significant barriers to enrollment: (1) the electronic health record was insufficient to determine the severity of patients' dementia; and (2) rates of follow-up survey completion were low, with completion rates at 6 months between 14 and 44%. We created an iterative training process to determine dementia severity from electronic health records and applied person-centered approaches to improve survey completion. Electronic health records are not set up to include discrete fields for dementia severity, which makes enrollment of older adults with dementia in a clinical trial challenging. The strain of caring for a loved one with advanced dementia may also make participation in health-services research difficult for patients and their families. Novel approaches have the potential to counteract these challenges, improve recruitment and retention, and ultimately improve care for people with dementia and their caregivers.

Machine learning-based model to predict delirium in patients with advanced cancer treated with palliative care: a multicenter, patient-based registry cohort

This study aimed to present a new approach to predict to delirium admitted to the acute palliative care unit. To achieve this, this study employed machine learning model to predict delirium in patients in palliative care and identified the significant features that influenced the model. A multicenter, patient-based registry cohort study in South Korea between January 1, 2019, and December 31, 2020. Delirium was identified by reviewing the medical records based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The study dataset included 165 patients with delirium among 2314 patients with advanced cancer admitted to the acute palliative care unit. Seven machine learning models, including extreme gradient boosting, adaptive boosting, gradient boosting, light gradient boosting, logistic regression, support vector machine, and random forest, were evaluated to predict delirium in patients with advanced cancer admitted to the acute palliative care unit. An ensemble approach was adopted to determine the optimal model. For k-fold cross-validation, the combination of extreme gradient boosting and random forest provided the best performance, achieving the following accuracy metrics: 68.83% sensitivity, 70.85% specificity, 69.84% balanced accuracy, and 74.55% area under the receiver operating characteristic curve. The performance of the isolated testing dataset was also validated, and the machine learning model was successfully deployed on a public website (http://ai-wm.khu.ac.kr/Delirium/) to provide public access to delirium prediction results in patients with advanced cancer. Furthermore, using feature importance analysis, sex was determined to be the top contributor in predicting delirium, followed by a history of delirium, chemotherapy, smoking status, alcohol consumption, and living with family. Based on a large-scale, multicenter, patient-based registry cohort, a machine learning prediction model for delirium in patients with advanced cancer was developed in South Korea. We believe that this model will assist healthcare providers in treating patients with delirium and advanced cancer.

Palliative care inpatients in Switzerland (2012–2021): characteristics, in-hospital mortality and avoidable admissions

ObjectivesPalliative patients generally prefer to be cared for and die at home. Overly aggressive treatments place additional strain on already burdened patients and healthcare services, contributing to decreased quality of...