Palliative Care Services For Patients Research Articles

Utilization of inpatient palliative care services in cardiac arrest complicating acute pulmonary embolism

IntroductionThe role of palliative care services in patients with cardiac arrest complicating acute pulmonary embolism has been infrequently studied. MethodsAll adult admissions with pulmonary embolism complicating cardiac arrest were identified using the National Inpatient Sample (2016–2020). The primary outcome of interest was the utilization of palliative care services. Secondary outcomes included predictors of palliative care utilization and its association of with in-hospital mortality, do-not-resuscitate status, discharge disposition, length of stay, and total hospital charges. Multivariable regression analysis was used to adjust for confounding. ResultsBetween 01/01/2016 and 12/31/2020, of the 7,320 admissions with pulmonary embolism complicating cardiac arrest, 1229 (16.8 %) received palliative care services. Admissions receiving palliative care were on average older (68.1 ± 0.9 vs. 63.2 ± 0.4 years) and with higher baseline comorbidity (Elixhauser index 6.3 ± 0.1 vs 5.6 ± 0.6) (all p < 0.001). Additionally, this cohort had higher rates of non-cardiac organ failure (respiratory, renal, hepatic, and neurological) and invasive mechanical ventilation (all p < 0.05). Catheter-directed therapy was used less frequently in the cohort receiving palliative care, (2.8 % vs 7.9 %; p < 0.001) whereas the rates of systemic thrombolysis, mechanical and surgical thrombectomy were comparable. The cohort receiving palliative care services had higher in-hospital mortality (85.7 % vs. 69.1 %; adjusted odds ratio 2.20 [95 % CI 1.41–3.42]; p < 0.001). This cohort also had higher rates of do-not-resuscitate status and fewer discharges to home, but comparable hospitalization costs and length of hospital stay. ConclusionsPalliative care services are used in only 16.8 % of admissions with cardiac arrest complicating pulmonary embolism with significant differences in the populations, suggestive of selective consultation.

The Paradox of Palliative Care at the End of Life: Higher Rates of Aggressive Interventions in Patients with Pancreatic Cancer.

Background: Palliative care has shown benefit in patients with cancer; however, little is known about the overall utilization of palliative care services in patients with pancreatic cancer and the impact of aggressive end-of-life interventions. This study aimed to explore the incidence of palliative care consultations (PCCs) in hospitalized patients with pancreatic cancer in the United States and the association between palliative care consultations and the use of aggressive interventions at the end of life. Methods: We conducted a retrospective study of patients hospitalized with pancreatic cancer. We examined patient records for 6 months prior to death for the presence of PCCs and aggressive end-of-life (EOL) interventions-emergency department visits, chemotherapy, and ICU stays. The use of EOL interventions was compared between those who did and those who did not receive PCCs, using Chi-square and Whitney U tests. Results: Of the 2883 identified patients, 858 had evidence of a PCC in their record in the last 6 months of life. Patients receiving PCCs were older at the time of death and more likely to receive chemotherapy (22.4% vs. 10.6%) in the last 6 months of life compared to those not receiving a palliative care consult. Similarly, patients with PCCs were more likely to have aggressive interventions in the EOL period. Conclusions: Less than 30% of patients with pancreatic cancer received a PCC. Those who received a PCC had more aggressive interventions in the end-of-life period, differing from what the prior literature has shown. Future investigations are necessary to explore the components and timing of PC and investigate their influence on the utilization of aggressive interventions and patient-centered outcomes.

Past trends and future projections of palliative care needs in Chile: analysis of routinely available death registry and population data

BackgroundThe number of people with palliative care needs is projected to increase globally. Chile has recently introduced legislation for universal access to palliative care services for patients with severe and terminal illnesses, including non-cancer conditions. We aimed to estimate the number of people affected by serious health-related suffering and need for palliative care in Chile to 2050.MethodsWe used data on all deaths registered in Chile between 1997-2019 and population estimates for 1997–2050. We used Poisson regression to model past trends in causes of death adjusted by age, sex and population estimates, to project the number of deaths for each cause from 2021 to 2050. We applied the Lancet Commission on Palliative Care and Pain Relief weights to these projections to identify decedents and non-decedents with palliative care needs.ResultsPopulation palliative care needs in Chile are projected to increase from 117 (95% CI 114 to 120) thousand people in 2021 to 209 (95% CI 198 to 223) thousand people in 2050, a 79% increase (IRR 1.79; 95% CI 1.78–1.80). This increase will be driven by non-cancer conditions, particularly dementia (IRR 2.9, 95% CI 2.85–2.95) and cardiovascular conditions (IRR 1.86, 95% CI 1.83–1.89). By 2050, 50% of those estimated to need palliative care will be non-decedents (not expected to die within a year).ConclusionsChile will experience a large increase in palliative care needs, particularly for people with dementia and other non-cancer conditions. Improved availability of high-quality services, expanded clinician training and new sustainable models of care are urgently required to ensure universal access to palliative care.

Palliative care needs and integration in severe COPD and ILD: Protocol of a mixed method study (PCIntegCOPD-ILD)

Background and Aim Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Lung Disease (ILD) have high symptom burden, serious health-related suffering, and mortality that necessitate palliative care (PC) integration. There is an information gap on PC needs, symptom burden, anxiety and depression in COPD and ILD, and the feasibility of PC integration from low-middle-income countries (LMICs). The PCIntegCOPD-ILD study aims to identify PC needs, symptom burden, and psychological distress in severe COPD/ ILD and assess the feasibility of PC integration within standard care. It will also explore experiences and unmet needs relating to disease and PC services for patients and informal carers. Methods and Design This mixed-methods study will assess PC needs, symptom burden, and psychological distress in patients with severe COPD (stages C, D) and ILD (stages II, III). Assessment will be done at recruitment (T0) and third (T3) month (face-to-face) and first (T1) and second (T2) month (phone call). After initial recruitment, patients will be provided PC interventions as required. At T3, patients’ and informal carers’ experiences and unmet needs of disease and PC services will be explored through semi-structured interviews. Impact and feasibility of integration of PC within standard care will also be assessed. Discussion The PCIntegCOPD-ILD study will provide robust data on PC needs, symptom burden, psychological distress and understanding of patient and caregiver perspecitves in severe COPD and ILD. An objective information on feasibility of PC integration will inform development and evaluation of similar models in the management of other progressive chronic diseases in LMICs.

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PurposeUpper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.MethodsWe conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019–2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.ResultsThe total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66–75 years 0.71, IRR 76–85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1–5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).ConclusionPeople with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Unlocking timely palliative care: assessing referral practices and barriers at a ghanaian teaching hospital

BackgroundThe need for primary care physicians to be heavily involved in the provision of palliative care is growing. International agencies and practice standards advocate for early palliative care and the use of specialized palliative care services for patients with life-threatening illnesses. This study was conducted to investigate physicians’ referral practices and perceived barriers to timely referral at the Korle Bu Teaching Hospital.MethodsA cross-sectional study design was employed using a convenience sampling technique to recruit 153 physicians for the study. Data on socio-demography, referral practices, timing and perceived barriers were collected using a structured questionnaire. Binary Logistic regression using crude and adjusted odds was performed to determine the factors associated with late referral. Significance was set at p < 0.05.ResultsThe prevalence of late referral was reported to be 68.0%. There were poor referral practices among physicians to palliative care services, and the major barriers to late referral were attributed to the perception that referring to a palliative care specialist means that the physician has abandoned his patient and family members’ decisions and physicians’ personnel choices or opinions on palliative care.ConclusionThe healthcare system needs tailored interventions targeted at improving physicians’ knowledge and communication strategies, as well as tackling systemic deficiencies to facilitate early and appropriate palliative care referrals. It is recommended that educational programs be implemented, palliative care training be integrated into medical curricula and culturally sensitive approaches be developed to address misconceptions surrounding end-of-life care.

Informed Consent and Surrogate Interference at the Initiation of Community-Based Palliative Care Services.

Community-based palliative care (CBPC) clinicians sometimes contend with an ethically charged scenario when they encounter patients for the first time: The patient's spouse, or other loved one or caregiver, revokes the patient's valid informed consent to initiate care. While surrogates are usually motivated by protective instincts, there are other situations where surrogates act out of self-interest. This article considers whether it is ever ethically justified for an adult to revoke another adult's valid informed consent to initiate palliative care services. The article examines this scenario from three perspectives: the patient's capacity to give or relinquish informed consent, the surrogate's intent and use of substituted judgment or best interest, and the clinician's duty to provide clinical care. This ethical analysis argues that CBPC clinicians have an ethical responsibility to provide palliative care services for patients who have given valid informed consent for those services even when a surrogate acts as an interfering or oppositional force.

Uptake of palliative care services in patients with non-small cell lung cancer receiving immune checkpoint inhibitor therapy: The Mayo Clinic Florida experience.

269 Background: There are strong data showing that patients (pts) with metastatic non-small cell lung cancer (NSCLC) receiving chemotherapy experience better quality of life (QOL) and longer overall survival (OS) when palliative care (PC) services are integrated early in their treatment course. Therefore, at our cancer center, pts with stage IV NSCLC have been referred to PC by oncology providers. In this study, we evaluated the uptake of PC services, specifically in pts with NSCLC who received immune checkpoint inhibitors (ICIs). ICIs have been considered to have less severe or less frequent adverse effects as compared to chemotherapy, possibly leading to fewer referrals to PC. Methods: We conducted a retrospective review of all pts at the Mayo Clinic Cancer Center in Florida who received single-agent ICI therapy for the treatment of stage IV NSCLC at any point between July 1, 2015, and July 1, 2022. The primary aim was to evaluate the uptake of PC services before or during treatment with ICIs. Descriptive statistics were used to characterize pt demographics and outcomes. Results: 129 pts were identified. 53.4% were male, and 46.6% were female. The majority of pts (84.4%) were white. 62 pts (48.0%) were seen by a PC provider before or during ICI treatment; 41 of these (31.7%) were seen by PC after starting ICI therapy. When grouped by year of ICI initiation, 30/73 pts (41.0%) treated between 2015 and June 2018 were seen by a PC provider, as compared to 15/31 pts (48.3%) treated between July 2018 and June 2020 and 17/25 pts (68.0%) treated between July 2020 and July 2022. Interestingly, the majority of pts who received PC services in the 2020-2022 group (12/17, or 70.5%) were seen by a PC provider for the first time prior to ICI initiation, whereas the majority of pts who received PC services prior to July 2020 (37/45, or 82.2%) were seen by a PC provider for the first time after ICI initiation. The mean number of PC visits increased from 1.59 in the 2015-2018 group to 1.84 in the 2018-2020 group and 4.96 in the 2020-2022 group. Conclusions: Uptake of PC services in pts with stage IV NSCLC receiving single-agent ICIs at our cancer center has increased over time, which is encouraging. Nevertheless, the numbers remain suboptimal, with less than 70% of pts receiving PC services. We plan to develop a multidisciplinary quality improvement project involving implementation of a mechanism to ensure that most patients with stage IV NSCLC, regardless of the type of systemic treatment they receive, are receiving PC services.

Prognosis Discussion and Referral to Community Palliative Care Services in Patients with Advanced Pancreatic Cancer Treated in a Tertiary Cancer Centre.

Advanced pancreatic cancer is associated with a poor prognosis, often less than 1 year. Honest prognosis discussions guide early community palliative care services input, facilitating timely advance care planning and improving quality of life. The aims were to assess if patients were offered prognosis discussions and community palliative care services referral. A retrospective analysis of consecutive case-notes of new advanced pancreatic cancer patients was conducted. Chi-squared test assessed the association with prognosis discussion and community palliative care services referral. In total, 365 cases (60%) had a documented prognosis discussion at any time-point in the treatment pathway; 54.4% during the first appointment. The frequency of prognosis discussion was greater with nurse clinician review at first appointment (p < 0.001). In total, 171 patients (28.1%) were known to community palliative care services at the first appointment. Of those not known, 171 (39.1%) and 143 (32.7%) were referred at this initial time-point or later, respectively. There was a significant association between the referral to community palliative care services at first appointment and the reviewing professional (this was greatest for nurse clinicians (frequency 65.2%)) (p < 0.001), and also if reviewed by clinical nurse specialist at first visit or not (47.8% vs. 35.6%) (p < 0.01). Prognosis discussions were documented in approximately two-thirds of cases, highlighting missed opportunities. Prognosis discussion was associated with clinician review and was most frequent for nurse clinician, as was referral to community palliative care services. Clinical nurse specialist review increased referral to community palliative care services if seen at the initial visit. Multi-disciplinary review, specifically nursing, therefore, during the first consultation is imperative and additive. It should be considered best practice to offer and negotiate the content and timing of prognosis discussions with cancer patients, and revisit this offer throughout their treatment pathway. Greater attention to prognosis discussion documentation is recommended.

S98 Utilizing Palliative Care Services in Patients With Pancreatic Cancer

S98 Utilizing Palliative Care Services in Patients With Pancreatic Cancer

Exploring the challenges and roles of nurses in delivering palliative care for cancer patients and co-morbidities in Ghana

BackgroundPatients suffering from chronic and life-threatening diseases receive inadequate palliative care in low-income countries, eventually leading to poor quality of life for these patients. Little is known about the experience of delivering palliative care in a low-resource country such as Ghana in comparison to higher-income countries. This study, therefore, aimed to assess the roles and challenges of nurses providing palliative care services for patients with cancer and life-limiting conditions at tertiary Hospitals in Ghana.MethodsThirty oncology nurses at a tertiary Hospital in Ghana participated. All nurses were providing end-of-life care to patients with cancer. A qualitative exploratory-descriptive design and a semi-structured interview guide developed by the researchers were used. Interviews lasted on average forty minutes to 1 h were audio-recorded, and transcribed verbatim. Content analysis was carried out to generate themes and sub-themes.FindingsParticipants were between the ages of 25 and 40 years. A higher percentage of females (n = 17, 57%) participated in the study than males (n = 13, 43%). Two main themes were generated which were the delivery of palliative care and the provision of home care services. The current roles of nurses were centered around pain management, home care services, spiritual needs, and psychological care. Challenges that hindered the implementation of palliative care included distress over expected and unexpected patient mortality, difficulty delivering bad news to patients and families, and frustration with health system resource shortages that negatively impacted patient care.ConclusionPalliative care is one of the essential services provided for patients with life-limiting conditions, and nurses play an active role in the provision of this care. Further research is needed to determine the most effective ways to deliver this care, particularly in developing nations like Ghana.

Hospice and Palliative Care for Patients in the Intensive Care Unit: Current Status in Countries Other than Korea.

Although most patients prefer dying at home, patients whose condition rapidly becomes critical need care in the intensive care unit (ICU), and it is rare for them to die at home with their families. Therefore, interest in hospice and palliative care for patients in the ICU is increasing. Hospice and palliative care (PC) is necessary for all patients with life-threatening diseases. The following patients need palliative care in the ICU: patients with chronic critical illnesses who need tracheostomy, percutaneous gastrostomy tube, and extracorporeal life support; patients aged 80 years or older; stage 4 cancer patients; patients with specific acute diseases with a poor prognosis (e.g., anoxic brain injury and intracerebral hemorrhage requiring mechanical ventilation); and patients for whom the attending physician expects a poor prognosis. There are two PC models-a consultative model and an integrative model-in the ICU setting. Since these two models have advantages and disadvantages, it is necessary to apply the model that best fits each hospital's circumstances. Furthermore, interdisciplinary decision-making between the ICU care team and PC specialists should be strengthened to increase the provision of hospice and palliative care services for patients expected to have poor outcomes and their families.

Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest.

Introduction: Previous research has shown limited palliative care (PC) utilization among patients evaluated for liver transplantation (LT) despite the cohort's significant symptom burden, high frequency of hospitalization and risk of rapid decompensation. Our aim was to evaluate patient characteristics and end-of-life (EOL) outcomes (i.e. ICU utilization, code status, advance care planning) associated with the use of PC services in patients who were evaluated for LT. Methods: We performed a single-center cross-sectional study comprised of 223 deceased patients evaluated for LT between 1/1/2017 and 12/31/2021. We evaluated demographic characteristics and EOL outcomes for differences between patients who received PC consultation and those who did not. EOL outcomes associated with PC use were assessed using logistic and linear regression analysis adjusted for patient demographics. Results: Patients who received PC consultation were younger (mean 57 vs. 61; P = 0.048), had higher Model for end-stage Liver Disease (MELD) scores (27.5 vs. 22; P = 0.001), higher rates of hepatic encephalopathy (96% vs. 84%, P = 0.005), and were more frequently declined for LT (77% vs. 57%; P = 0.008). Patients who received PC services were less likely to die in the ICU (OR = 0.07 [0.02-0.18]) and were more likely to have documented advance care planning (OR = 3.16 [1.47-6.97]), family meetings (OR = 6.58 [2.72-17.08]), and goals-of-care discussions (OR = 14.83 [4.39-69.29]). Conclusion: For patients being evaluated for LT, PC utilization differed based on demographics, disease complications and severity, and transplant status. Those who received PC services had higher quality EOL care planning and fewer ICU admissions.

A Retrospective, Single-Center Analysis of Specialized Palliative Care Services for Patients with Advanced Small-Cell Lung Cancer.

Simple SummaryPatients with advanced small-cell lung cancer (SCLC) have a considerable symptom burden and may require extensive care. A crucial element of treatment for these patients is the integration of specialized palliative care (SPC). Timely integration of SPC for patients with advanced non-small cell lung cancer (NSCLC) improved quality of life and prolonged survival in large prospective trials. This study provides retrospective data for patients with SCLC with, and without SPC. The results and conclusions indicate that patients with advanced SCLC should participate in a consultation with a SPC team in a timely manner to ensure a benefit of SPC for this patient group.Timely integration of specialized palliative care (SPC) has been shown to improve cancer patients’ quality of life (QoL) and reduced the use of medical services. To evaluate the level of integration of SPC services for patients with advanced small-cell lung cancer (SCLC), we retrospectively analyzed medical records of patients from 2019 to 2021. Regarding the timing of referral to SPC services, we defined four cutoffs for early referral according to the current literature: (a) SPC provided ≤ 60 days after diagnosis; (b) SPC provided ≥ 60 days before death; (c) SPC provided ≥ 30 days before death; and (d) SPC provided ≥ 130 days before death. One hundred and forty-three patients (94.1%) were found to have locally advanced (stage III) or metastatic (stage IV) disease. Sixty-eight were not referred to SPC services (47.6%), whereas 75 patients received SPC (52.4%). We found a significantly higher number of referrals to SPC services for patients with higher ECOG (Eastern Cooperative Oncology Group) (i.e., ECOG ≥ 2) (p = 0.010) and patients with stage IV disease (p ≤ 0.001). The median overall survival (OS) for SCLC stage III/IV patients (n = 143) who did not receive SPC treatment was 17 months (95% CI 8.5–25.5), while those who did receive SPC treatment had a median OS of 8 months (95% CI 6.2–9.8) (p = 0.014). However, when we evaluated patients receiving SPC treatment in a timely manner before death as suggested by the different cutoffs indicated in the literature, they lived significantly longer when referred at a minimum of ≥60 or ≥130 days before death. Based on our findings, we suggest that patients with advanced SCLC should participate in a consultation with a SPC team in a timely manner to ensure a benefit of SPC for this patient group.

Trigger-based pathways to increase utilization of palliative care services for cancer patients: A multi-disciplinary approach.

e24007 Background: Palliative care involves services to improve the quality of life for chronically ill patients and their care teams. Use of palliative care has shown to decrease the utilization of resources and increase clarity of goals of care. Although acceptance of palliative care principles has been improving, we conducted a multidisciplinary project to increase the utilization of palliative care consult (PCC) and follow its effect of hospital-based outcome. Methods: IRB approved study involving patients on medical floors and in the ICU were conducted over 3 months with 1-month pre-intervention phase (PIP). We developed PCC triggers based on medical literature for the ICU and Medical floors to identify at risk patients likely to benefit from PCC on admission. Trigger questionnaire included but was not limited to the problem list at admission, comorbidities, requirements and availability of social support, and age &gt; 80 years which were reviewed by the primary Nursing staff at admission assessment. Patients meeting any one of the triggers were eligible for PCC. The RNs would reach out to the primary team to notify them of patient’s eligibility for PCC. We adopted “opt in” model to request approval of the PCC. Outcomes measures included rate of PCC among triggered, code status change, and discharge planning. Triggers for pre-intervention were filled by EHR review. All the categorical variables were compared by chi-square test. Results: 344 (Median age - 69, 50.58% Female) patients were enrolled during the study with 93 (27.03%) cancer patients. 93/121 (76.86%) of PIP patients and 160/223 (71.74%) of intervention phase (IP) patients triggered the PCC. During PIP, proportion of triggered non-cancer and cancer patients referred for PCC were 9/73 (12.33%) and 6/20 (30.00%) respectively. During IP, proportion of triggered patients referred for PCC significantly increased compared to PIP to 28/99 (28.28%, p-value – 0.01) and 38/61 (62.30%, p-value – 0.01) for both non-cancer and cancer patients, respectively. During the IP, PCC was recommended significantly more times (p-value – 0.00) in cancer patients than non-cancer patients. Among all with PCC involved, 4/17 (23.59%) PIP and 8/59 (13.56%, p-value – 0.56) IP full-code cancer patients changed code status to DNR. Among the cancer patients, 10 (6 from ICU and 4 from medical floor) patients were discharged to home hospice compared to none in pre-intervention phase. Conclusions: Application of trigger-based pathways leads to early and increase utilization of palliative care services for all patients by identifying patients to benefit from early PCC. Among cancer patients, we found improvement in utilization of hospice services and clarification of their code status at discharge. Further studies are needed to standardize the procedure for increased integration of PCC into our hospital’s clinical models of care.

Implementation of an integrated respiratory palliative care service for patients with advanced lung disease.

Objectives This study describes the model of care provided by an integrated respiratory and palliative care service for patients with advanced lung disease, and assesses the potential impact of the service on acute hospital utilisation and cost. Methods This study implemented an integrated specialist care service at a single tertiary teaching hospital in Melbourne, Victoria, Australia. The service provided disease-orientated care, alongside symptom management and advance care planning, and comprised both outpatient clinic (OPC) and home visit (HV) capacity for those with barriers to accessing OPC. Acute hospital utilisation and hospital cost were analysed with a paired t -test 90 days before/after the first physician review. Results Between April 2017 and 2019, 51 patients received 59 HVs, whereas between July 2018 and 2020, 58 patients received 206 OPC reviews. Acute hospital admissions decreased by 51% in the HV cohort (P < 0.05) and by 46% in the OPC cohort (P = 0.01); total bed days of acute admissions decreased by 29% in the HV cohort (P = n.s.), and by 60% in the OPC cohort (P < 0.05); and specialist outpatient clinic attendances decreased in the OPC cohort by 55% (P < 0.01). There was a decrease in hospital cost for the HV cohort by 3% (cost savings of A$18 579), and in the OPC cohort by 23% (cost savings of A$109 149). Conclusions This model of care provided specialist respiratory management with seamless integration of palliative care, with the capacity for home visits. There was a decrease in acute hospital utilisation and overall cost savings observed in both HV and OPC cohorts.

Telemedicine Utilization in the Ambulatory Palliative Care Setting: Are There Disparities?

ContextGiven a shortage of specialty palliative care clinicians and geographic variation in availability, telemedicine has been proposed as one way to improve access to palliative care services for patients with cancer. However, the enduring digital divide raises questions about whether unequal access will exacerbate healthcare disparities. ObjectivesTo examine factors associated with utilization of telemedicine as compared to in-person visits by patients with cancer in the ambulatory palliative care setting. MethodsWe collected data on patients seen in Supportive Oncology clinic by palliative care clinicians with an in-person or telemedicine visit from March 1 to December 30, 2020. A logistic regression with generalized estimating equation was fit to assess the association between visit type and patient characteristics. ResultsA total of 491 patients and 1783 visits were identified, including 1061 (60%) in-person visits and 722 (40%) telemedicine visits. Female patients were significantly more likely to utilize telemedicine than male patients (OR 1.46; 95% CI 1.11–1.90). Spanish-speaking patients (OR 0.32, 95% CI 0.17–0.61), those without insurance (OR 0.28, 95% CI 0.15–0.52), and those without an activated patient portal (Inactivated: OR 0.46, 95% CI 0.26–0.82; Pending Activation: OR 0.29, 95% CI 0.18–0.48) were less likely to utilize telemedicine. ConclusionOur study reveals disparities in telemedicine utilization in the ambulatory palliative care setting for patients with cancer who are male, Spanish-speaking, uninsured, or do not have an activated patient portal. In the wake of the COVID-19 pandemic, we can better meet the palliative care needs of patients with cancer through telemedicine only if equity is kept at the forefront of our discussions.

Utilization of palliative care services in patients who died from stage IV non-small cell lung cancer (NSCLC): A retrospective study from a tertiary care center in rural Maine.

95 Background: It is known that palliative care involvement in metastatic NSCLC cancer patients has been shown to improve quality of life in previous studies. The aim of our study was to analyze the utilization of palliative care services among patients who died from NSCLC and the setting in which these patients first received palliative care. Methods: This is a retrospective chart review analysis of patients with stage IV NSCLC who were diagnosed at Eastern Maine Medical center and the affiliated cancer center who died between January 2016 and December 2018. We collected demographic data, date and stage of diagnosis, location of palliative referral, location of first palliative care contact with the patient, time between diagnosis and death, utilization of hospice services and time between the initial palliative care consult and death. Results: 255 patients with stage IV NSCLC died between 2016 and 2018. Mean age was 65.5 years. Women were 49% and men were 51%. Majority (60%) of patients had good performance status with ECOG score between 0-1 at presentation. All 255 patients were referred to palliative care. The location of initial palliative care referral following diagnosis was 40% from the hospital, 32% from the oncology clinic and 28% from the outpatient specialist or PCP office. Overall, 174 patients (68%) were seen by palliative care and 81 (32%) were not seen. Of the patients seen 119 (68%) had their initial palliative evaluation in the hospital, and 55 (32%) in the clinic. Majority (55%) had more than one follow-up visit. Consults initiated in the inpatient setting were more likely to be seen by palliative care than in the outpatient setting (p 0.0009). Time between diagnosis to palliative care consult was less than one month in 39%, 1-2 months in 25%, 2-6 months in 21%, and more than 6 months in 14% patients. Patients seen by palliative care had a more likelihood to end up on hospice (p 0.09). The majority of patients seen by palliative care (53%) died within a month of initial consultation. Conclusions: All patients in our study population were referred to palliative care with 100% provider compliance. Among these, 68% were seen by palliative care. Interestingly, inpatient referrals were more likely to be seen by palliative care than the outpatient referrals. We think this is likely related to ease of access to palliative care team in the hospital as well as some of the patients being at terminal stages of their disease. About 33% of patients died within a month of their initial diagnosis, likely giving palliative care team a shorter window of opportunity to be seen in the outpatient setting. Prioritizing referrals of stage IV NSCLC patients might decrease the wait time after initial referral and increase the availability of palliative care services to these patients.

Palliative care physicians' recognition of patients after immune checkpoint inhibitors and immune-related adverse events.

This study investigated the experience of palliative care physicians (PCPs) and their knowledge and recognition of immune checkpoint inhibitors (ICIs) and immune-related adverse events (irAEs) in clinical practice as well as the need to provide palliative care services for patients after ICI treatments. A cross-sectional survey with self-administered questionnaires was conducted between February and April 2020. A total of 759 questionnaires were sent to PCPs in Japan. The changes in the PCPs' knowledge and recognition of ICIs and irAEs due to the increased experiences of treating patients after ICI treatments were analyzed. Four hundred ninety-two responses (64.8%) were analyzed. Only 15.0% of respondents had no experience of patients after ICI treatments, while 53.9% had experience of more than six patients. On the other hand, 40% of respondents had no experience of patients with suspected irAEs, while only 13.4% had experience of more than six patients.Respondents with more experience of patients after ICI treatments or those with suspected irAEs hadextensive knowledge of ICIs and irAEs, were more confident in treating these patients, and tended toconsider irAEs as therapeutic indications. The majority of respondents required guidelines and efficient consultation systems with oncologists. This study demonstrated that PCPs with experience had extensive knowledge and confidence of ICIs and irAEs and tended to recognize irAEs as therapeutic indications. The establishment of a more intimate relationship between PCPs and oncologists is important for providing better treatment for these patients.

Palliative Care Services in Patients Admitted With Cardiogenic Shock in the United States: Frequency and Predictors of 30-Day Readmission

BackgroundPatients admitted with cardiogenic shock (CS) have high mortality rates, readmission rates, and healthcare costs. Palliative care services (PCS) may be underused, and the association with 30-day readmission and other predictive factors is unknown. We studied the frequency, etiologies, and predictors of 30-day readmission in CS admissions with and without PCS in the United States. Methods and ResultsUsing the 2017 Nationwide Readmissions Database, we identified admissions for (1) CS, (2) CS with PCS, and (3) CS without PCS. We compared differences in outcomes and predictors of readmission using multivariable logistic regression analysis accounting for survey design. Of 133,738 CS admissions nationally in 2017, 36.3% died inpatient. Among those who survived, 8.6% used PCS and 21% were readmitted within 30 days. Difference between CS with and without PCS groups included mortality (72.8% vs 27%), readmission rate (11.6% vs 21.9%), most frequent discharge destination (50.2% skilled nursing facilities vs 36.4% home), hospitalization cost per patient ($51,083 ± $2,629 vs $66,815 ± $1,729). The primary readmission diagnoses for both groups were heart failure (32.1% vs 24.4%). PCS use was associated with lower rates of readmission (odds ratio, 0.462; 95% confidence interval, 0.408–0.524; P < .001). Do-not-resuscitate status, private pay, self-pay, and cardiac arrest were negative predictors, and multiple comorbidities was a positive predictor of readmission. ConclusionsThe use of PCS in CS admissions remains low at 8.6% in 2017. PCS use was associated with lower 30-day readmission rates and hospitalization costs. PCS are associated with a decrease in future acute care service use for critically ill cardiac patients but underused for high-risk cardiac patients.