Palliative Care Referral In Patients Research Articles

Gender and Generational Divide Between Surgeons Regarding Preoperative Palliative Care Referral for Patients with Resectable Pancreatic Cancer: Results from an International Survey

INTRODUCTION: Preoperative palliative care (PC) consultation has been proposed for patients with resectable gastrointestinal cancer. Two randomized trials are evaluating PC and surgeon comanagement in the perioperative setting. We hypothesized that pancreatic surgeons harbor significant reservations regarding providing palliative care in parallel with potentially curative surgery. METHODS: An anonymous international web-based survey was conducted in 2021. Chi-square test or Fisher’s exact test were used for categorical questions, and the Wilcoxon test was used for Likert-scaled questions. Statistical significance was set at p < 0.05. RESULTS: A total of 138 surveys were completed. Of these, 83% of surgeons were male, 85% completed a fellowship, 80% practiced in academia, 46% performed more than 30 annual curative-intent operations for PDAC, and 90% had been in practice 30 or fewer years. Of those surveyed, 88% of surgeons were from the US. Of those surveyed, 65% of surgeons supported introducing PC preoperatively; female surgeons (p = 0.018) and fellowship-trained surgeons (p = 0.002) significantly more likely supported this practice; however, surgeons in practice more than 30 years did not support preoperative PC referral (p = 0.003). Of those surveyed, 94% of surgeons identified benefits associated with preoperative PC consultation; female surgeons (p = 0.048; odds ratio 3.03; CI 097. to 9.45) and fellowship-trained surgeons (p = 0.016; odds ratio 4.17; CI 1.30 to 13.33), were more likely to report that preoperative PC consultation may improve symptoms management. US surgeons identified more benefits and challenges related to preoperative PC consultation compared with non-US surgeons. CONCLUSION: Most surgeons recognize the potential benefit of preoperative PC consultation and comanagement. However, gender, fellowship training, and years in practice impact surgeons’ preference. Further studies are needed to elucidate patient and other stakeholder perspectives on preoperative PC-surgeon comanagement.

S1172 Early Palliative Care Referral May Improve End of Life Care in End-Stage Liver Disease Patients. A Retrospective Analysis From a Non-Transplant Center

Introduction: Patients with End Stage Liver Disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of transplant-ineligible patients with ESLD. Methods: We conducted a retrospective analysis of adult patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on presence (Group 1) or absence (Group 2) of PC involvement. Baseline characteristics were recorded. Impact of PC was assessed by comparing number of hospitalizations before and after PC referral, comparing code status changes, health care proxy (HCP) assignments, and requirement of repeated paracentesis. Results: 576 patients were analyzed of which 237 received a PC consult (Group 1) and 339 did not (Group 2). Baseline characteristics were comparable in both groups (Table). Mortality rate was significantly higher in group 1 than group 2 (83.1 vs 46.4%, p < 0.01). Changes in code status were higher in group 1 than in group 2 (77.6% vs 29.2%, p < 0.001). 59.9% in group I had comfort care code status and 67.8% in group 2 had full code. Patients in group 1 were more likely to have an HCP assigned (63.7% vs 37.5%, p < 0.001). Aspira catheter use (5.9% vs 0.9%, p < 0.001) and hospitalizations for frequent paracentesis (30.8% vs 16.8%, p < 0.001) were both more frequent in group 1. Mean number of emergency room visits or hospitalizations before the first PC consult was 15.6 and mean number of admissions after PC consult was 3.4 (P< 0.001). Conclusion: Our study shows that PC referral in patients with ESLD is associated with a higher rate of code status changes, HCP assignments and reduced hospitalizations. Patients receiving a PC referral were more likely to have a comfort care status while patients without a PC referral were more likely to be full code. Mortality rates at our non-transplant center were higher in patients with palliative care referral than those without. It suggests that patients did not receive a PC referral unless their disease severity was significant, however all patients with ESLD may benefit from early PC referral. Table 1. - Baseline characteristics and outcomes Variable PC involved (237) PC not involved (339) P-value Age (years) 64.61 64.07 0.58 Sex (% male) 57.40% 55.20% 0.59 Hepatocellular carcinoma 11 (4.6%) 12/339 (3.5%) 0.38 Transplant referral done 41 (17.3%) 72/339 (21.2%) 0.29 Mortality 196 (83.1%) 157 (46.4%) < 0.0001 Aspira catheter 14 (5.9%) 3 (0.9%) < 0.001 Frequent paracentesis 73 (30.8%) 57 (16.8%) < 0.001 TIPS procedure 8 (3.4%) 24 (7.1%) 0.06 Code status changes 184 (77.6%) 99 (29.2%) < 0.001 Full code 44 (18.6%) 230 (67.8%) < 0.001 Comfort care 142 (59.9%) 70 (20.6%) < 0.001 HCP assignments 151 (63.7%) 127 (37.5%) < 0.001

Male and Senior Surgeons are Less Likely to Support Preoperative Palliative Care Referral for Patients with Resectable Pancreatic Cancer: Results from an International Survey

Background: Preoperative palliative care (PC) consultation has been proposed for patients with resectable gastrointestinal cancers. Two randomized trials are evaluating PC and surgeon co-management in the perioperative setting. We hypothesized that pancreatic surgeons harbor significant reservations regarding providing palliative care in parallel with potentially curative surgery. Methods: An anonymous international web-based survey was conducted in 2021. Chi-square and Wilcox tests were used for categorical and for Likert scaled questions respectively. Statistical significance set at p<0.05. Results: 138 surveys were completed. 83% of surgeons were male, 85% completed a fellowship, 80% practice in academia, 46% perform >30 annual curative-intent operations for PDAC and 90% have been in practice ≤ 30 years. 88% of surgeons were from the US. 65% of surgeons support introducing PC preoperatively; female surgeons (p=0.018) and fellowship-trained surgeons (p=0.002) were significantly more likely to support this practice, however, surgeons in practice >30 years do not support preoperative PC referral (p=0.003). 94% of surgeons identified benefits associated with preoperative PC consultation; female surgeons (p=0.048; OR 3.03 [CI:097.-9.45]) and surgeons with fellowship training (p=0.016; OR 4.17 [CI:1.30-13.33]), were more likely to report that preoperative PC consultation may improve symptoms management. US surgeons identified more benefits and challenges related to preoperative PC consultation compared to non-US surgeons (Table 1). Discussion: Most surgeons recognize potential benefits of preoperative PC consultation and co-management. However, gender, fellowship training, and years in practice impact surgeon’s preference. Further studies are needed to elucidate patient and other stakeholder perspectives on preoperative PC-surgeon co-management.

Implementing 'Goals of Care' discussion and palliative care referral for patients with advanced lung cancer: an outpatient-based pilot project.

Early involvement of palliative care and advance care planning improves quality-of-life outcomes and survival for patients with advanced lung cancer; however, there are barriers to implementation. A single-centre prospective audit reviewing 'Goals of Care' (GOC) form completion and palliative care referrals in an oncology clinic was undertaken with the aim of increasing GOC completion and palliative care referrals for patients with advanced lung cancer. Involved physicians attended a communication skills course and then received a communication-priming intervention. Clinicopathological factors associated with GOC completion and palliative care referral were explored. A total of 84 patients receiving palliative treatment for advanced lung cancer was enrolled. Clinicopathological factors, such as poorer performance status, were associated with higher likelihood of GOC completion (P = 0.018) prior to the intervention. Male sex (P = 0.023), absence of sensitising epidermal growth factor receptor mutation or anaplastic lymphoma kinase rearrangement (P = 0.017), type of systemic therapy (P = 0.031) and poorer performance status (P < 0.001) were associated with higher likelihood of palliative care referral. The intervention improved GOC completion (relative risk (RR) 1.29, P = 0.004); however, this was not sustained in a follow-up audit (RR 0.98, P = 0.92) and there was no change in palliative care referral rate (RR 2.5, P = 0.16). Predictors of palliative referral following clinical review included age (RR 1.16, P = 0.001), male sex (RR 14.2, P = 0.02) and poorer performance status (RR 1.76, P < 0.001). Communication-priming interventions can improve GOC completion for patients with advanced lung cancer. Further investigation is needed to pursue sustainable options for managing this complex patient group and improve guideline-adherence and patient care.

Timing of palliative care referral in patients with advanced Non-Small Cell Lung Cancer: a retrospective cohort study

Introduction: Early palliative care referral is recommended for patients with Stage IV Non-Small Cell Lung Cancer (NSCLC) irrespective of the decision to administer cancer-directed therapies. Diagnosis-to-referral and referral-to-death intervals, proposed as measures of quality of care, are rarely reported in low-and-middle income settings. Objective: to estimate the 6-month cumulative incidence of palliative care referrals and the length of referral-to-death intervals among patients with Stage IV NSCLC at a teaching hospital in Argentina. Methods: Patients with Stage IV NSCLC diagnosed between 2012 and 2017 were followed up until December 2019. We retrieved the first contact with palliative care services and date of death from centralized Electronic Health Records. Cumulative incidence of palliative care referrals was estimated by fitting a Fine & Gray competing risks model. Results: Ninety-two patients were included. Median age was 71.5 years (IQR 63–79 years), 55% were women. Median survival time was 375 days (95% CI: 204–508 days). Considering death as a competing risk, the 6-month cumulative incidence of palliative care referrals was 37% (95% CI: 27% to 47%). Among referred patients, the median referral-to-death interval was 31 days. Discussion: Further research should focus on identifying and overcoming barriers to timely palliative care referrals in this population.

Assessment of feasibility and utility of universal referral to specialty palliative care in a multidisciplinary amyotrophic lateral sclerosis clinic: A cohort study.

Although the value of palliative care integration in multidisciplinary amyotrophic lateral sclerosis (ALS) clinics has been increasingly recognized, limited data are available demonstrating the feasibility and utility of a palliative care specialist embedded in an ALS clinic. The purpose of this study is to describe the feasibility and utility of a universal outpatient referral model for specialty palliative care for patients with amyotrophic lateral sclerosis. This is a retrospective cohort study of initial patient visits with a palliative care physician in a multidisciplinary ALS clinic at an academic institution. All patients were referred to an embedded palliative care physician from January to December 2019. Within the study period, 52 of 69 (75%) patients with a confirmed diagnosis of ALS were seen by the palliative care physician. The most common reason patients were not seen by palliative care was a lack of insurance authorization (n=5). At the visit, 94% of patients discussed at least one advance care planning or goals of care topic. The most common advance care planning topic discussed was code status (40%). The most common goals of care topic discussed was meaning and values (57%). Symptom management was discussed with 40 patients (77%). The most common symptom addressed was pain and/or muscle spasms (33%). These data support the feasibility and utility of universal, outpatient palliative care referral for patients with ALS. Further research is necessary to determine the long-term effect on outcomes for this population.

Using Quality Improvement to Increase Access to Palliative Care.

As part of a larger effort to integrate palliative care into a cancer center, we identified barriers to palliative care referral for patients with breast or gynecologic cancer and developed a pilot program to improve access to palliative care services. We developed a multidisciplinary steering committee to uncover barriers to palliative care referral and developed a pilot program, called the Warm Handoff. Through ongoing collaboration and midpilot feedback sessions, we identified several additional barriers and opportunities to increase access to palliative care. Clinicians used the initial Warm Handoff process only 20 times over a period of 7 months. Of those calls, 10 were for issues outside of those that the Warm Handoff pilot was intended to address. During the pilot, we identified lack of access to urgent visits and clinician telephone availability for clinical case discussion as additional barriers to access. Increased collaboration led to the creation of a clinical provider of the day (CPOD) care model, which allowed for a notable increase in the capacity to see urgent consults. After this intervention, we observed an average of 19 patients seen urgently per month. In addition, there was a trend toward increasing referrals from breast oncology after the initiation of the CPOD. A CPOD model, developed via close oncology/palliative care collaboration, resulted in increased utilization of palliative care services.

Medical oncologist perspectives on palliative care reveal physician-centered barriers to early integration.

Background:Early palliative care referral for patients with advanced cancer has demonstrable benefits but is underutilized. We sought to characterize medical oncologists’ perceptions about palliative care referral in their clinical practices.Methods:We conducted 4 focus groups with a national sample of medical oncologists to elicit perspectives about the optimal timing of and barriers to palliative care referral for patients with cancer. We used qualitative content analysis to uncover themes related to early integration of palliative care into standard oncologic practice.Results:Study participants readily acknowledged the evidence supporting early palliative care referral. However, medical oncologists identified patient-centered and physician-centered barriers to widespread adoption of early palliative care. Patient-centered barriers included patients’ and families’ perceptions or misperceptions of the role of palliative care. Additionally, physicians themselves described acting as a barrier to palliative care referral because they were concerned that palliative care physicians may interfere with the plan of care, or offer options that were not endorsed by the medical oncologist. Medical oncologists depicted themselves having authority over the timing of palliative care referral, and as granting limited autonomy to other clinical team members in counseling patients about advanced care planning.Conclusions:Medical oncologists are hesitant to adopt the practice of early palliative care referral because they are concerned that other physicians may disrupt a patient’s treatment plan. Physician-centered barriers may delay integration of palliative care, and future efforts to promote a collaborative approach to advanced care planning may improve patient-centered outcomes through access to early palliative care.

Referral Criteria to Palliative Care for Patients With Heart Failure: A Systematic Review.

Patients with heart failure have significant symptom burden, care needs, and often a progressive course to end-stage disease. Palliative care referrals may be helpful but it is currently unclear when patients should be referred and by whom. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with heart failure. We searched Ovid, MEDLINE, Ovid Embase, and PubMed databases for articles in the English language from the inception of databases to January 17, 2019 related to palliative care referral in patients with heart failure. Two investigators independently reviewed each citation for inclusion and then extracted the referral criteria. Referral criteria were then categorized thematically. Of the 1199 citations in our initial search, 102 articles were included in the final sample. We identified 18 categories of referral criteria, including 7 needs-based criteria and 10 disease-based criteria. The most commonly discussed criterion was physical or emotional symptoms (n=51 [50%]), followed by cardiac stage (n=46 [45%]), hospital utilization (n=38 [37%]), prognosis (n=37 [36%]), and advanced cardiac therapies (n=36 [35%]). Under cardiac stage, 31 (30%) articles suggested New York Heart Association functional class ≥III and 12 (12%) recommended New York Heart Association class ≥IV as cutoffs for referral. Prognosis of ≤1 year was mentioned in 21 (21%) articles as a potential trigger; few other criteria had specific cutoffs. This systematic review highlighted the lack of consensus regarding referral criteria for the involvement of palliative care in patients with heart failure. Further research is needed to identify appropriate and timely triggers for palliative care referral.

Barriers to goals of care discussion and early palliative care referral in patients with advanced cancer: A community oncology clinic survey.

e19199 Background: Earlier discussion of end-of-life (EOL) preferences in patients with advanced cancer is associated with less aggressive EOL care. Most terminally-ill patients have not discussed their goals of care (GOC) with their healthcare providers before becoming acutely ill. Identifying various barriers in the outpatient setting might help improve GOC discussion and EOL experience for patients with advanced cancer. Methods: This cross sectional survey was designed after a thorough literature review and distributed to internal medicine residents, oncologists and oncology nurses involved in patient care in an outpatient cancer center at a community hospital. Barriers to GOC discussions and early palliative care (PC) referral were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important). Most important barrier was defined by people ranking it as very important or extremely important (6 or 7). A total of 33 health care providers were included in the final analysis. Trends were reported using descriptive statistics. Results: Patient/family related barriers were ranked the highest overall. 88% of respondents perceived patient’s difficulty in accepting prognosis as most important, followed by lack of agreement among family members (82%) and patient wanting to be 'aggressive' (82%). Among groups, 100% (6 of 6) oncologists perceived patient wanting to be ‘aggressive’ as the most important barrier, whereas disagreement among family members and patient’s difficulty in accepting poor prognosis was perceived as most important by 88% (7 of 8) nurses and 84% (16 of 19) residents respectively. Nurses also ranked patient's difficulty in understanding limitations of life sustaining treatments high. 67% of respondents, especially nurses and residents, perceived lack of training to have GOC conversations as the most important health care provider related barrier. Patient’s refusal for PC services was rated as the most important barrier for early PC referral by 61% of respondents, however, oncologists (100%) ranked lack of outpatient PC services the highest. Conclusions: These results emphasize the need for better resources to improve communication between health care providers and cancer patients in an outpatient setting. Initiatives such as formal training and targeted education in communication about GOC to health care providers can be instrumental in addressing these barriers. Integration of outpatient palliative care services into community-based oncology can be beneficial.

Real-world evidence highlights sizeable gap in adopting early palliative care referral in patients with advanced cancers.

e24147 Background: Early referral to palliative care (PC) for patients w/ adv cancer is supported by compelling evidence from large RCTs demonstrating a lower symptom burden, higher QOL, and increased OS. However, these studies reflect pts who have self-selected to accept a PC referral and attend a PC visit. WHO/NCCN/ASCO guidelines support early integration of PC. We sought to characterize the referral patterns in our heme/onc practice to identify and mitigate the barriers to early PC adoption in the community setting. We began a concerted effort to discuss early PC referral w/ pts recently diagnosed w/ adv cancer at the time systemic therapy was initiated. Methods: To ensure real-world applicability of this study, we identified a large satellite clinic of a major academic center w/ access to PC on the main campus (located 20 miles from the satellite clinic). We retrospectively reviewed new pts age 18y+ w/ adv cancer, characterized PC referrals and outcomes. Using qualitative methodology, we identified pt-reported barriers to accepting PC care. Results: 407 new pts were seen; 168 w/ benign heme, 145 w/ early cancers, 94 w/ adv cancers. Of the 94 pts w/ adv cancers, 25 pts had one-time 2ndopinion visits, and 16 pts were not candidates for, or did not desire cancer treatment and directly enrolled on hospice. Our analysis cohort consisted of 53 pts w/ adv cancer pursuing life prolonging therapy. At initiation of treatment, 57 % (n=30) were not offered a PC referral, 22% (n=12) received a PC referral and attended the appt, however 21% (n=11) received a PC referral but did not attend the appt. A qualitative analysis of the 11 patients referred to early PC who did not attend the appt revealed; 5 patients scheduled an appt but did not attend (3-unknown reason, 2-hospitalized during appt, 1-lack of transportation), 2 pts were unreachable, and 4 pts were contacted but declined to schedule stating: “I feel pressured” “I want to hear what other treatment options I have” “I want to be treated first and then see if I need it” "I am overwhelmed with too many new doctors and visits". Conclusions: Despite the benefit of early PC referral in pts w/ adv cancer, we identified a considerable gap in its adoption in our community practice despite access to proximate PC clinic. Further studies are under design to address institutional and pt-related factors to improve real-world adoption of this critical service.

"Triggers" for early palliative care referral in patients with cancer: a review of urgent unplanned admissions and outcomes.

Benefits of early palliative referral in oncology are well documented. Palliative care referral "triggers" may help identify patients for referral. Many triggers have been proposed, but are not commonly used. This study reviewed the timing of palliative care involvement for patients in a tertiary referral oncology hospital, and whether the use of a trigger tool prior to admission would have facilitated earlier referral. This was a retrospective cohort study of cancer patients who died during an unplanned admission between November 2014 and October 2015. A literature review identified seven palliative care referral tools which were included in this analysis, and compared by identifying common themes. Each tool was applied to patients by reviewing electronic patient records. Timing of palliative referral and whether patients met any triggers within 6 months before their terminal admission were assessed. A total of 159 patients were identified. Forty-six percent were referred to palliative care prior to terminal admission. Application of 6 out of 7 trigger tools would have resulted in the majority of patients (up to 91.2%) referred to palliative care prior to admission. Most patients (52.2%) were referred only during their terminal admission. Patients known to palliative care before admission (N = 73) were reviewed quicker than those who were not (N = 86) (median (range) 1 day (0-23 days) versus 5 days (0-59 days), p < 0.00001). In this patient cohort, a palliative referral trigger tool may have proactively identified most patients prior to their terminal admission. Prospective testing of trigger tools in oncology populations is warranted.

Hepatobiliary and Pancreatic: Early palliative care referral in patients with end‐stage liver disease is associated with reduced resource utilization

Palliative care referral for end stage liver disease (ESLD) is uncommon and usually occurs late. We aimed to review the rate of early palliative care referral (EPCR) in ESLD patients, its associations, and its impacts on resource utilisation and survival. A retrospective review of all patients with ESLD admitted to a single hepatology unit between 2013 and 2016. Inclusion criteria for study entry were at least two admissions for decompensated liver disease within a six month period and not eligible for liver transplantation. The EPCR group was defined as those patients who received palliative care referral at least 30 days prior to mortality. 74 patients were included in the study. EPCR rate was 19%. On multivariate analysis EPCR was associated with hepatocellular carcinoma (OR 4.47, 95% CI 1.02-19.5, p=0.047), and negatively associated with alcoholic liver disease (OR 0.16, 95% CI 0.032-0.88 p=0.035). There was no difference in survival based on EPCR status. Hospitalization costs were lower in the EPCR group (p=0.027). There was also a significantly lower number of endoscopies (p=0.009), and blood transfusions (p=0.001) in the EPCR group. EPCR was also associated with higher rates of outpatient palliative care and advanced care planning. EPCR in ESLD was uncommon and associated with hepatocellular carcinoma and lack of alcoholic liver disease. EPCR was associated with decreased resource utilisation and further high quality studies are required to confirm the benefits of EPCR in ESLD.

Outpatient palliative care and thoracic medical oncology: Referral criteria and clinical care pathways

ObjectivesRecent evidences show that early integration of palliative care (PC) with oncology has a positive impact on patients' quality of life, quality of care and costs. However, there is no consensus on outpatient referral criteria. Based on real world data, the aim of this study was to identify timing and factors associated to PC referral in patients with thoracic malignancies, and to describe their clinical care pathway. Material and MethodsThis observational retrospective study included consecutive patients with thoracic cancer, seen for the first time at the Thoracic Medical Oncology outpatient Clinic (TMOC) of our institution, between Jan.01-Dec.31 2014. Patients were followed-up till death or Dec.31 2015. Clinical and demographic data were collected from the electronic patient records. Cox regression models were used to evaluate the association between time to Palliative care Outpatient Clinic (POC) referral and performance status (PS), disease stage and symptoms at inclusion. Results229 patients were eligible. 98 of them (43%; 95%IC 36%–49%) were referred to the POC within a median of 30 days (IQR 4–188). 80/98 patients received simultaneous anticancer therapy and PC. Univariable analysis showed that the hazard ratio (HR) of being referred to POC was significantly higher for patients with worse PS (HR = 4.5), more advanced disease stage (HR = 3.1), pain (HR = 4.9), dyspnea (HR = 2.5) and cough (HR = 2.2). The multivariable model confirmed independent prognostic value for PS, disease stage and pain. On Dec.31, 2015, 25/98 patients were still alive, 8 were lost at follow up and 65 had died. Among the latter, 61% died with hospice or home care, and, in the last 30 days of life, 16% received chemotherapy and 29% were admitted to hospital. ConclusionsOur results suggest considering symptom burden, PS and disease stage as screening criteria for referral to PC in patients with thoracic malignancies.

ED-PALS: A Comprehensive Palliative Care Service for Oncology Patients in the Emergency Department.

The American College of Emergency Physicians has identified early palliative care referral for patients with advanced cancer as a key competent of the Choosing Wisely campaign. To study the feasibility of a new 3-way model of care between emergency department (ED), hospital palliative care department, and inpatient/home hospice. This was a prospective, descriptive study that included oncology patients who attended the hospital ED over a 3-year period from January 2015 to December 2017. The inclusion criteria were as follows: (1) presence of metastatic cancer with either; (2) any 1 of the following symptoms: pain, dyspnea, nausea and vomiting, delirium, or swelling; or (3) potential care difficulties (requiring home hospice care or inpatient hospice). A total of 340 patients were referred from the ED. Mean age was 72 years, 59% were males and 41% females, and the majority (88%) were Chinese. The most common cancers were lung 89 (26%), colorectal 71 (21%), and hepatobiliary cancer 49 (14%). The most common symptoms on Edmonton Symptom Assessment Scale scoring were pain (34%), poor appetite (31%), and dyspnea (26%). This tripartite model of palliative care, hospice, and ED collaboration allows earlier access to palliative care in the ED and direct admissions to the palliative care unit and comfort care rooms. The ED patients who did not need admission were also attended to in the palliative care "Hot Clinics" within a week with home hospice help. Patients who required inpatient hospice care were directly admitted there from the ED.

Reducing the percent of ICU deaths of patients with advanced cancer at Stanford.

234 Background: Intensive care at the end of life, for patients with advanced cancer can compromise quality of life and result in excessive costs for patients and their families. In 2014, 40% of patients with solid tumors admitted to the Stanford Health Care ICU died with advanced stage disease. Sixty-five percent of the patients with advanced stage saw palliative care (PC) &lt; 7 days of life. The aim was to decrease the percent of advanced solid tumor ICU deaths by 25%, through early palliative care intervention. Methods: The current process was analyzed through mapping and a cause and effect diagram. The outcome measure was defined as percentage of patients with advanced solid tumors dying in ICU. A key intervention was the development of criteria designed to trigger an earlier PC referral for patients with stage III-IV lung/pancreatic cancer. PC referral triggers included: 2+ lines of prior chemotherapy with life expectancy &lt; 6 months or refractory disease, hospitalization within prior 30 days, &gt; 7days of hospitalization, uncontrolled symptoms. ICU trainees were to contact the primary oncologists and discuss the role of PC consultation for patients who met the criteria. A balance measure was developed to assess if primary oncologists were contacted. Charts of patients admitted to the ICU 2 weeks pre- and post-implementation were reviewed. Results: During the pre-PDSA cycle, 13 patients with cancer were admitted to the ICU while 10 were admitted post-PDSA cycle. Primary oncologists of the patients with advanced cancer who met our criteria were contacted in similar rate pre- and post-PDSA (39% vs 40%). PC consultation was also similar for pre- and post-PDSA cycles (31% vs 30%). The percent of ICU deaths of patients in the pre-PDSA was 22% and 22% in the post-PDSA cycles. Conclusions: The percentage of deaths in the ICU for patients with advanced cancer met our target goal of 25% reduction from the baseline. However, the improvement was independent of our intervention, given the timing and short interval. The percent of PC consults for patients meeting the criteria did not change. Data from subsequent PDSA cycles and a SPC chart will be reported in the conference.

Outcomes of lung transplant candidates referred for co-management by palliative care: A retrospective case series

Background: Lung transplant candidates experience important symptoms, but they are rarely referred for palliative care consultation until they are deemed ineligible for transplant. Our lung transplant service has a high rate of palliative care referral for patients awaiting transplant. Aim: We reviewed the characteristics, interventions, and outcomes of lung transplant candidates referred for co-management by palliative care, to determine whether they safely received opioids and went on to transplantation. Design and participants: Retrospective review of lung transplant candidates referred to our palliative care consultation service between January 2010 and May 2012. Results: Of 308 lung transplant candidates, 64 (20.7%) were referred to palliative care. Most had interstitial lung disease and were referred for dyspnea and a rapidly deteriorating course. A total of 59 (92%) were prescribed opioids for dyspnea, 55/59 used the opioids more than once, and 38/59 were maintained on standing opioids. There were no episodes of clinically important opioid toxicity or respiratory depression, and there was a trend toward increased exertion during exercise sessions post-opioid versus pre-opioid (19.3 vs 17.0 kcal, respectively, p = 0.06). At last follow-up, 30 (47%) had been transplanted, 23 (36%) had died while on the wait-list, 9 (14%) had died after delisting, and 2 (3%) were still awaiting transplantation. Of the 30 patients who underwent lung transplantation, only 7 (23%) still required an opioid prescription 1 month post-discharge. Conclusion: In lung transplant candidates, palliative care and opioids in particular can be safely provided without compromising eligibility for transplantation. Palliative care should not be delayed until a patient is deemed ineligible for transplant.

Overcoming the Barriers to Palliative Care Referral for Patients With Advanced Heart Failure

In the care of seriously ill patients, cardiologists and other physicians must have many skills to effectively help the patient and family manage the symptoms from the illness, cope with and understand the likely illness trajectory, and navigate complex medical decision making. Cardiologists