Palliative Care Unit Admission Research Articles

Integrating palliative care into multiple myeloma management : Optimizing quality of life across the disease continuum.

Multiple myeloma (MM) poses significant challenges due to its complex symptomatology and evolving treatment landscape. While therapeutic advances have improved survival outcomes, holistic management of MM requires addressing the numerous physical and psychosocial needs of patients. Palliative care (PC) offers acomprehensive approach to symptom management and supportive care on aphysical, psychosocial and spiritual level; however, its role in MM remains underexplored. This retrospective single-center study examines the outcome of 22 MM patients admitted to the Division of Palliative Medicine at the Medical University of Vienna. We investigated reasons for admission, symptom severity, functional status, length of stay and overall survival. Most common reasons for palliative care unit (PCU) admission were nutritional problems (82%), fatigue (77%) and pain (68%). Median ECOG score at PCU admission was 3. The timepoint within the timeline of myeloma disease at which hospitalization took place varied greatly. Some patients were hospitalized shortly after diagnosis, other patients after many years of active disease and therapy. Median time from MM initial diagnosis to first PCU stay was 4.3years (range 0.6-23.8 years). The median length of hospital (PCU) stay was 11days (range 1-127days) and 45% of patients died during PCU hospitalization. The reduction in symptom burden as aresult of the inpatient stay in the PCU is reflected in the PERS2ON score, which was measured on the day of admission (median23 days, range 6-32days) and on the day of discharge (median16 days, range 7-20days). PC interventions effectively addressed the complex symptom burden experienced by patients with MM. Multidimensional approaches encompassing physical, psychological and social domains proved instrumental in optimizing quality of life. Integrating PC principles into MM management paradigms is essential to prioritize patient-centered care across the disease continuum.

Polypharmacy and Potentially Inappropriate Medications in Patients With Advanced Cancer: Prevalence and Associated Factors at the End of Life.

Background: Polypharmacy and potentially inappropriate medications (PIMs) impose a burden on patients with advanced cancer near the end of their lives. However, only a few studies have addressed factors associated with PIMs in such patients. Objective: To examine polypharmacy and factors associated with PIMs in end-of-life patients with advanced cancer. Design: Retrospective chart review. Setting/Subjects: We analyzed 265 patients with advanced cancer who died in a palliative care unit (PCU) or at home in a home medical care (HMC) from April 2018 to December 2022 in Japan. Measurements: Sociodemographic, clinical, and prescription data at the time of PCU admission or HMC initiation were collected from electronic medical records. PIMs were assessed using OncPal Deprescribing Guidelines. Results: Patients with advanced cancer with an average age of 76.3 years and median survival days of 20 were included in the analyses. The average number of medications was 6.4 (standard deviation = 3.4), and PIMs were prescribed to 50.2%. Frequent PIMs included antihypertensive medications, peptic ulcer prophylaxis, and dyslipidemia medications. A multivariate logistic regression analysis revealed that age ≥75 years (adjusted odds ratio [aOR] = 2.30, 95% confidence interval [CI] = 1.30-4.05), referral from an outpatient setting compared with inpatient setting (aOR = 2.06, 95% CI = 1.12-3.80), more than two comorbidities (aOR = 1.88, 95% CI = 1.08-3.29), and more than five medications (aOR = 1.84, 95% CI = 1.03-3.28) were associated with PIMs. Conclusions: Medication reconciliation is recommended at the time of transition to a PCU or HMC, especially for older patients with advanced cancer who were referred from an outpatient setting and present more comorbidities and prescriptions.

Extended-hours palliative care service with a hospital-avoidance and enhanced-care approach: report of a quality improvement project.

A community palliative care service (CPCS) identified its after-hours support as sub-optimal in avoiding acute hospitalisation and supporting patients to remain at home. It created and conducted a pilot of an extended hours palliative care service (EHPCS) using current resources. To evaluate the efficacy of an extended hours palliative care service pilot. Retrospective chart review of after-hours calls taken before the trial, usual care, was undertaken. During the trial, quantitative data was gathered of the outcome of each after-hours call, including outcomes of occasion of service, reason for and length and times of calls. The extended hours palliative care service, compared with usual care, showed an almost 50% decrease in acute hospitalisation, nearly doubled after-hours palliative care unit admission and a 17% increase in patients staying in their home. EHPCS was positively received by CPCS staff, despite cost and workforce impact. EHPCS can positively impact on reducing avoidable hospitalisations and facilitate palliative care patients to be in their preferred place of care.

Earlier palliative home care is associated with patient-centred medical resource utilisation and lower costs in the last 30 days before death in COPD: a population-level decedent cohort study

COPD patients often use many medical resources, such as hospital admissions and medical imaging, inappropriately close to death. Palliative home care (PHC) could beneficially affect this. The aim was to study the effect of use and timing of PHC on medical resource use and costs in the last 30 days before death (DBD) for COPD.We performed a retrospective study of all Belgian decedents in 2010-2015 with COPD and a primary cause of death being COPD or cardiovascular diseases. Odds ratios for medical resources were calculated between using and four PHC timing categories (>360, 360-181, 180-91 and 90-31 DBD) versus not using. Confounders were socio-demographic, care intensity and disease severity variables.Of the 58 527 decedents with COPD, 644 (1.1%) patients received PHC earlier than 30 DBD. Using PHC (versus not using) decreased the odds ratio for hospitalisation (0.35), intensive care unit admission (0.16), specialist contacts (0.58), invasive ventilation (0.13), medical imaging including chest radiograph (0.34), sedatives (0.48) and hospital death (0.14). It increased the odds ratio for home care (3.27), general practitioner contact (4.65), palliative care unit admission (2.61), noninvasive ventilation (2.65), gastric tube (2.15), oxygen (2.22) and opioids (4.04) (p<0.001). Mean total healthcare costs were €1569 lower for using PHC. All PHC timing categories showed a benefit in medical resource use and costs. However, we observed the largest benefit in the category PHC 90-31 DBD.Health policy and services should focus on increasing PHC access, while research should further explore early PHC initiation for COPD.

Does Use and Timing of Palliative Home Care Have an Effect on Medical Resource Use in the Last Thirty Days Before Death in COPD? A Full-Population Retrospective Study

Background: COPD patients often use extensive medical resources, e.g. frequent hospitalisations, when they are close to death. Palliative home care (PHC) could affect end-of-life medical resource use. However, population studies studying this possible effect for COPD are lacking. Aim: To study the effect of use and timing of PHC on medical resource use in the last 30 days before death (DBD) for COPD. Methods: Retrospective study of all Belgian decedents in 2010-2015 who died with COPD. Odds ratios (OR) for medical resources in the last 30 DBD were calculated between using versus not using PHC, and between four PHC timing categories (>360; 360-181; 180-91; 90-31 DBD) versus not using PHC. Confounders were socio-demographic, care intensity and disease severity variables. Results: Of the 58,527 decedents with COPD, 644 patients (1.1%) received PHC before 30 DBD. Using PHC (versus not using) decreased the OR for hospitalisation (0.35), intensive care unit admission (0.16), specialist contacts (0.58), invasive ventilation (IV) (0.13), medical imaging including chest radiograph (0.34), sedatives (0.48) and hospital death (0.14). It increased the OR for home care (3.27), general practitioner contact (4.65), palliative care unit admission (2.61), non-IV (2.65), gastric tube (2.15), oxygen (2.22), opioids (4.04) and morphine (5.29) (p 360 DBD (p<0.001). Conclusion: PHC use is associated with less extensive medical resource use in the last 30 DBD for COPD. Health policy and services should focus on increasing PHC access, while research should further explore the effects of early initiation of PHC for COPD. Funding: (SBO IWT nr. 140009). Declaration of Interest: The authors declare no conflict of interest. Ethical Approval: The ethics committee of the Ghent University Hospital granted its approval (B670201422382).

Interprofessional Collaboration Between a Multidisciplinary Palliative Care Team and the Team Pharmacist on Pain Management

The purpose of the study was to evaluate the impact on pain management by multidisciplinary palliative care team (mPCT) and the team pharmacist. Patients who were admitted to palliative care unit (PCU) for at least 7 days between April 2014 and December 2015 were included. The mPCT consisted of a physician, a pharmacist, nurses, and non-clinical support staff. The team was on charge of pain management of patients who were admitted to PCU. Pain intensity was assessed at 3 time points in each patient; 1 week before PCU admission (day -7), on the day of admission (day 0), and 1 week after admission (day 7) using 0 to 10 numerical rating scale (NRS). Analgesic use was evaluated with 6 categories based on National Comprehensive Cancer Network and Korean pain management guidelines. Pain intensity and analgesic use appropriateness were compared at day -7, day 0, and day 7 for the patients who were admitted to the PCU. Pain intensity decreased significantly on day 7 of PCU admission compared to it on day 0 (NRS: 4.05 vs 2.66, P < .001). A significant negative correlation was found between pain intensity and the proper use of analgesics ( r = -0.407; P < .001, r = -0.309; P = .001, r = -0.241; P = .009, on day -7, day 0, day 7, respectively). The mPCT contributed to the reduction of inappropriate use of analgesics and improved pain control. Pharmacist intervention appeared to have improved pain control in patients under palliative care. Each team member's role should be individualized and developed further.

CNS Metastases in Epidermal Growth Factor Receptor Mutation-Positive Non-Small-Cell Lung Cancer: Impact on Health Resource Utilization.

Patients with epidermal growth factor receptor (EGFR) mutation-positive (EGFRm) non-small-cell lung cancer commonly experience disease progression in the CNS. Here, we assess the impact of CNS disease on resource utilization and outcomes in patients who are EGFRm. We completed a retrospective review of all advanced patients who were EGFRm, referred to BC Cancer, and treated with a first- and/or second-generation EGFR tyrosine kinase inhibitor from 2010 to 2015. Baseline characteristics, systemic treatment, and CNS management were collected. We compared health resource utilization (HRU) between patients with CNS-negative disease and those with CNS metastases from the median time of CNS metastases diagnosis to death or last follow-up (9.1 months) and at 9 months preceding death or last follow-up for the CNS-negative group. Four hundred ninety-nine patients were referred, of which 68% were female; 51% were of Asian ethnicity; and 57%, 37%, and 6% were exon 19, 21, or other, respectively; with a median age of 66 years. Two hundred twenty-nine (46%) of 499 patients developed CNS metastases-39% at diagnosis and 61% over the course of disease. CNS metastases were managed with surgery with or without whole-brain radiotherapy (WBRT; 13%) WBRT alone (73%), stereotactic radiosurgery with or without WBRT (5%), or no CNS-directed therapy (9%). The median time from the development of CNS metastases diagnosis to death was 9.1 months. CNS-negative patients used less HRU versus patients that were CNS-positive in the 9 months preceding death or last follow-up-in the average number of clinic visits (8.53 v 12.71, respectively; P < .001), hospitalizations (0.43 v 0.76, respectively; P < .001), CNS imaging investigations (0.52 v 2.65, respectively; P < .001), emergency room visits (0.03 v 0.14, respectively; P = .001), palliative care unit admission (8% v 10%, respectively; P = .64), and hospice admission (3% v 19%, respectively; P < .001). The incidence of CNS metastases in patients with EGFRm is high and associated with increased HRU. Prevention or delay of CNS metastases with newer systemic therapy options may translate into lower resource utilization.

Palliative Performance Scale Score at 1 Week After Palliative Care Unit Admission is More Useful for Survival Prediction in Patients With Advanced Cancer in South Korea.

The Palliative Performance Scale (PPS) is a useful prognostic index in palliative care. Changes in PPS score over time may add useful prognostic information beyond a single measurement. To investigate the usefulness of repeated PPS measurement to predict survival time of inpatients with advanced cancer admitted to a palliative care unit (PCU) in South Korea. Prospective observational cohort study. 138 patients with advanced cancer admitted to a PCU in a university hospital in South Korea from June 2015 to May 2016. The PPS score was measured on enrollment and after 1 week. We used Cox regression analyses to calculate hazard ratios (HRs) to demonstrate the relationship between survival time and the groups categorized by PPS and changes in PPS score, after adjusting for clinical variables. There were significant differences in survival time among 3 groups stratified by PPS (10-20, 30-50, and ≥60) after 1 week. A group with a PPS of 10 to 20 at 1 week had the highest risk (HR: 5.18 [95% confidence interval, 1.57-17.04]) for shortened survival. On the contrary, there were no significant differences among these groups by initial PPS alone. Similarly, change in PPS was prognostic; median survival was 13 (10.96-15.04) days for those whose PPS decreased after 1 week and 27 (10.18-43.82) days for those with stable or increased PPS ( P < .001). Measuring PPS over time can be very helpful for predicting survival in terminally ill patients with cancer, beyond a single PPS measure at PCU admission.

Palliative radiotherapy utilization within a regional Australian palliative care unit.

Palliative radiotherapy has been demonstrated to be efficacious for symptom management in advanced malignancy however there are limited data investigating its use for inpatient palliative care patients. The aim of the current paper was to evaluate the utilization of radiotherapy amongst patients admitted to a regional Australian palliative care unit (PCU). A retrospective cohort study was undertaken involving all Barwon Health PCU patients who received radiotherapy whilst an inpatient. A range of clinico-demographic, radiotherapy-specific and outcome measures were evaluated. Changes in opioid consumption were used as a surrogate for radiotherapy effectiveness. Demographic variables were analyzed descriptively and Wilcoxon Signed Rank Tests were used to compare opioid consumption before and after radiotherapy at time points one week, two weeks and three weeks. Sixty episodes of radiotherapy were provided to 51 PCU patients during the study period with 54 admissions included in the final analysis. Pain management was the commonest reason for radiotherapy treatment and most courses were multi-fractionated. Using the proportion of patients whose opioid dose decreased following radiotherapy as a marker for response, response rates ranged from 32-42%. Fortyeight percent of patients died during their PCU admission and the median survival from radiotherapy commencement was 36 days. A small proportion of all patients admitted to PCU received radiotherapy. Almost half of patients died during their admission and radiotherapy response rates were lower than have been reported for all-comers. More research is needed to optimize the stratification of PCU patients for radiotherapy.

Palliative radiotherapy utilization within a regional Australian palliative care unit

Background: Palliative radiotherapy has been demonstrated to be efficacious for symptom management in advanced malignancy however there are limited data investigating its use for inpatient palliative care patients. The aim of the current paper was to evaluate the utilization of radiotherapy amongst patients admitted to a regional Australian palliative care unit (PCU). Methods: A retrospective cohort study was undertaken involving all Barwon Health PCU patients who received radiotherapy whilst an inpatient. A range of clinico-demographic, radiotherapy-specific and outcome measures were evaluated. Changes in opioid consumption were used as a surrogate for radiotherapy effectiveness. Demographic variables were analyzed descriptively and Wilcoxon Signed Rank Tests were used to compare opioid consumption before and after radiotherapy at time points one week, two weeks and three weeks. Results: Sixty episodes of radiotherapy were provided to 51 PCU patients during the study period with 54 admissions included in the final analysis. Pain management was the commonest reason for radiotherapy treatment and most courses were multi-fractionated. Using the proportion of patients whose opioid dose decreased following radiotherapy as a marker for response, response rates ranged from 32–42%. Fortyeight percent of patients died during their PCU admission and the median survival from radiotherapy commencement was 36 days. Conclusions: A small proportion of all patients admitted to PCU received radiotherapy. Almost half of patients died during their admission and radiotherapy response rates were lower than have been reported for all-comers. More research is needed to optimize the stratification of PCU patients for radiotherapy.

Can We Detect Transfusion Benefits in Palliative Care Patients?

Red blood cell (RBC) transfusions are commonly prescribed for palliative care patients for symptoms. However, RBCs are a limited resource, transfusion is not without risk, and may be of variable benefit in people approaching the end of life. The aim of this study was to review RBC transfusions in our palliative care unit (PCU), examining evidence of benefit or harms, and preparing for a prospective multisite study. This consecutive cohort study retrospectively reviewed transfusions administered during a PCU admission. Hemoglobin levels, physical function, and symptom rating for breathing and fatigue (Symptom Assessment Scale) were assessed before transfusion, and at days 2 and 7. Thirty-one patients received 44 transfusions over the two-year period. Of these patients, the average age was 64 years and 45% were male. Eighty-nine percent of transfusions were thought to be of subjective benefit by clinicians, and 94% of patients reported symptomatic improvement. However, overall, there was little change in scale-based measures of physical function or symptoms, with response rates <25% in all scales. No predictors of response were found considering pretransfusion hemoglobin, hemoglobin increment, Australia-modified Karnofsky Performance Status, or discharge status. Deterioration after transfusion was prevalent. For RBC transfusion in palliative care patients, the majority had subjective benefit. However, subjective improvement correlated poorly with objective scale-based measures. The sensitivity of assessment scales, high rates of placebo response, and the multifactorial nature of symptoms at the end of life make evaluation of RBC transfusions challenging.

Characteristics and outcomes of advanced cancer patients admitted to an acute palliative care unit (PCU) with severe dyspnea receiving high flow oxygen (HFO).

247 Background: Dyspnea is very complex and distressing symptom in patients with advanced cancer. The therapeutic goal of its symptomatic management is to relieve the patient’s breathlessness sensation. Limited literature has addressed the characteristics and clinical outcomes of advanced cancer patients with severe dyspnea receiving HFO admitted to PCU. Methods: We reviewed the records of 101 advanced cancer patients with dyspnea receiving HFO and 110 matched PCU inpatients with dyspnea receiving regular O2 flow (NoHFO) between January 1 to December 31, 2012. Demographics, frequency and intensity of symptoms at PCU admission and follow-up, and outcomes were recorded. Results: Median age: 60 years, range (51, 69). 56% were Male. White(71%), Hispanic(13%), African American(10%), Asian (4%). Primary cancer: Lung (27%), Gastrointestinal (19%), Hematological (18%), Breast (13%), Gynecological (6%). Dyspnea was present in all cases and it was related mainly to: lung involvement by cancer (53%), pneumonia (40%), Congestive Heart Failure (6%), COPD (8%). ECOG: 4. No significant difference in age, ethnicity and type of cancer, ECOG, and possible cause of dyspnea among both groups. HFO and NoHFO were started the same day of admission. Median ESAS symptoms (Interquartile range: IQR) for HFO was Pain 4.5 (2, 7) vs. 5 (3, 7) for NoHFO, p = 0.1423; fatigue [7(5, 8) vs. 7 (5, 8), p = 0.450]; depression [3 (1, 5) vs. 3.5 (2, 5), p = 0.81]; anxiety 7 (4, 9) vs. 6 (3, 8), p = 0.01; dyspnea [7.5( 6, 9) vs. 5 (3, 8), p &lt; 0.0001]. Memorial Delirium Scale 5 (2, 15) vs. 7(2, 15), p = 0.77). Morphine Equivalent Daily Dose: 48 (36, 120) vs. 55 (30, 120), p = 0.72. The median difference among first and follow up ESAS was Pain 0 (-3, 1) vs. -1(-2, 1), p = 0.62; fatigue[(-2, 1) vs. 0 (-2, 0), p = 0.63]; depression [0 (-1, 1) vs. 0 (-1, 2), p = 0.93]; anxiety [0 (-2, 2) vs. 0 (-2, 2), p = 0.94; dyspnea [0( -1, 1) vs. -1 (-2, 1), p = 0.18]. Memorial Delirium Scale 0 (-1.5, 5.5) vs. 0 (-2, 3), p = 0.21).The median time (IQR) from HFO started to discharge was 10 days (6, 15) vs. 8.5 (5, 14) days for NoHFO, p = 0.07). The median time(IQR) from HFO started to Death was 10.5 (7, 19) vs. 13.5 (7, 26) days for NoHFO, p = 0.18. 77/101(76%) HFO patients vs. 56/110 (51%) NoHFO died at the hospital, p = 0.002. 24/101(23%) HFO patients were discharged alive weaned off HFO. The Odd ratio for hospital death in patients with HFO vs. NoHFO was 4.83 (95% CI: 1.72 – 13.59), p = 0.003. Conclusions: Severe dyspnea is significant at the end of life of advanced cancer patients. Patients with HFO require similar MEDD than NoHFO patients. Inpatient mortality is higher in patients with HFO. More research is needed.

End-of-life cancer care: Health service delivery in the last 12 months of life in Calgary, Alberta, Canada.

171 Background: In Calgary, Alberta, the Calgary Zone Palliative Care Collaborative (CZPCC) undertook a study to examine the current state of cancer and palliative services and to recommend steps to address gaps in service delivery. We hypothesized that early access to palliative care services would reduce utilization of active cancer treatments and services for individuals nearing the end of life. Our study objectives were to determine the utilization and timing of acute, palliative and oncology-related services in Calgary. Methods: This retrospective study examined cancer registry and administrative data for patients &gt; 18 years, who died in 2012. Measures of aggressive end of life care (EOL) were also collected. A combination of descriptive statistics, tests of association and multivariate regression analysis were conducted. Results: N = 1909 died of cancer in 2012: median age 73 years (IQR: 62-82 years) and median disease duration 364 days (IQR: 92-1114 days). 40.6% of patients received systemic treatment in last 12 months of life. 29.9% received radiotherapy and 13.0% received psychosocial/spiritual care. Palliative care contact was 80.7%, inclusive of 20.6% who had an intensive palliative care unit admission. 5.2% had EOL chemotherapy and 3.8% received EOL radiotherapy. Up to 10.4% of patients had one or more hospital admission. There was no significant effect of age on those who received aggressive EOL care. Men had an increased probability to receive aggressive EOL care (p = 0.015). Tumor group was also associated with receiving aggressive EOL (p &lt; 0.001), with the highest utilization in Head and Neck and hematological malignancies. In patients with a disease duration of &gt; 4 months those who received palliative care at least 2-3 months prior to death were less likely to receive aggressive EOL care (P &lt; 0.001). Patients whose disease duration was &lt; 1 month were less likely to receive aggressive EOL care if they received palliative care services (p = 0.02). Conclusions: The provision of palliative care services at the end of life is most needed among men and certain tumor groups who are the highest users of aggressive EOL care.

緩和ケア病棟入院前後に患者・家族がもつ情報の程度や理解状況─看護師による評価から

緩和ケア病棟入院前後に患者・家族がもつ情報の程度や理解状況─看護師による評価から

Uncertain Cancer Diagnosis: The Expanded Role of the Palliative Care Consultant

As attending physicians in acute care hospitals consult palliative care services earlier for patients with a life-threatening illness, the role of the palliative care consultant (PCC) may expand, especially when there is diagnostic uncertainty. The expanding role of the PCC and the complexities associated with earlier referral are illustrated by describing the case of a patient with an uncertain diagnosis. The diagnostic uncertainty that accompanies earlier palliative care consultation may hamper the PCC's ability to establish goals of care and the appropriateness of hospice palliative care unit admission. Attempts at resolving this diagnostic uncertainty may lead to an expanded role for the PCC, which ideally will occur in collaboration with the primary care team.

Survival Duration among Patients with a Noncancer Diagnosis Admitted to a Palliative Care Unit: A Retrospective Study

Palliative care unit (PCU) beds are a limited resource in Canada, so PCU admission is restricted to patients with a short prognosis. Anecdotally, PCUs further restrict admission of patients with noncancer diagnoses out of fear that they will "oversurvive" and reduce bed availability. This raises concerns that noncancer patients have unequal access to PCU resources. To clarify survival duration of patients with a noncancer diagnosis, we conducted a retrospective review of all admissions to four PCUs in Toronto, Canada, over a 1-year period. We measured associations between demographic data, prognosis, Palliative Performance Score (PPS), length of stay (LOS), and waiting time. We collected data for 1000 patients, of whom 21% had noncancer diagnoses. Noncancer patients were older, with shorter prognoses and lower PPS scores on admission. Noncancer patients had shorter LOS (14 versus 24, p<0.001) than cancer patients and a similar likelihood of being discharged alive to cancer patients. Noncancer patients had a trend to lower LOS across a broad range of demographic, diagnostic, prognostic, and PPS categories. Multivariable analysis showed that LOS was not associated with the diagnosis of cancer (p=0.36). Noncancer patients have a shorter LOS than cancer patients and a similar likelihood of being discharged alive from a PCU than cancer patients, and the diagnosis of cancer did not correlate with survival in our study population. Our findings demonstrate that noncancer patients are not "oversurviving," and that referring physicians and PCUs should not reject or restrict noncancer referrals out of concern that these patients are having a detrimental impact on PCU bed availability.

Factors Influencing Survival after Discharge from an Australian Palliative Care Unit to Residential Aged Care Facilities: A Retrospective Audit

Increasing demand for palliative care unit (PCU) beds has led to shorter inpatient stays and a requirement to transfer some patients from a PCU to a residential aged care facility (RACF). Concerns have been raised regarding this move with suggestion that patients often die shortly after transfer. Published data investigating this patient group are limited. The aim of the current study was to audit discharges from a PCU to RACFs specifically looking at predictive factors for survival following discharge. A retrospective audit was undertaken of all discharges from the Barwon Health PCU to RACFs between July 2007 and July 2010. Data on patient demographics, clinical and functional status, admission and discharge details, and survival times were examined. Factors influencing survival were evaluated by Cox proportional-hazards regression analysis. Sixty-two discharges from a PCU to an RACF were included in the analysis. The mean age at discharge was 76 and the majority of patients had malignant disease. Mean and median survival times post-transfer were 106 and 42.5 days, respectively, and 16% of subjects survived more than 100 days. From univariate analyses age, PCU length of stay, admission Resource Utilization Groups-Activities of Daily Living (RUG-ADL) score, dependent mobility, having lung cancer or cancer of unknown primary, and living alone or in an RACF pre PCU admission affected survival. Multivariate analyses showed age, PCU length of stay, RUG-ADL score, and living situation prior to PCU admission together were associated with postdischarge survival times. This study is one of the largest investigating this cohort and suggests a number of factors that may predict survival for patients after discharge from a PCU to an RACF.

Changes in medical and nursing care after admission to palliative care units: a potential method for improving regional palliative care

The purpose of the study was to evaluate changes in medical and nursing care for patients just after admission to a palliative care unit (PCU) from general wards in one city. Subjects were 260 consecutive patients admitted to a PCU. Data on changes in medical and nursing care occurring just after admission were collected prospectively using a structured data collection sheet about four areas: (1) medical treatment, (2) nursing care, (3) giving additional information about the patient's condition to the patient and/or the family, and (4) obtaining psychosocial information. The mean number of total changes was 8.0 +/- 5.6 per patient. The most common changes in medical treatment were initiation or increase of opioids (18%), discontinuation or decrease in artificial hydration (16%), initiation of steroids (13%), initiation of antiemetics (9%), initiation of antibiotics (8%), and initiation of nonsteroidal anti-inflammatory drugs (7%). The most common changes in nursing care were starting oral care (19%), permission to take a bath (11%), and change in the pattern of meals (8%). Information about the patient's condition was given most frequently to key family members (27%). Psychosocial information obtained most frequently was about the family's expectations regarding the PCU and insight into the patient's condition (53% and 41%, respectively). Changes in medical and nursing care were frequent, and the frequency of local healthcare providers' assessment of the changes may be insufficient. Providing general ward staff with data about changes in interventions occurring just after PCU admission might be effective for improving palliative care for terminal patients.

Factors associated with mortality in an inpatient acute palliative care unit at a comprehensive cancer center

20756 Background: Predicting inpatient mortality has clinical and financial implications and helps improve the care of advanced cancer patients and their families. Models are available for mortality prediction in intensive care units with excellent validity and reliability. The purpose of this study was to determine factors associated with increased likelihood of mortality in an acute palliative care unit (PCU). Methods: We reviewed the medical records of 357 patients admitted to the PCU and collected information regarding demographic factors, tumor type, hospital length of stay, source of admission, and insurance type. Symptom intensity, vital signs, relevant laboratory tests and presence/absence of delirium were obtained from the palliative care consultation preceding PCU admission. Univariate and multivariate analyses were conducted to compare factors in patients who died in the PCU vs. those who were discharged alive. Results: 93 (26%) patients died in the PCU. The results for univariate and multivariate analyses are described in the table. Surprisingly, no statistically significant association was found between inpatient death and delirium or low lymphocyte percentage. Borderline association was found between inpatient death and high bilirubin, high LDH, elevated white blood cell counts and also with hematologic malignancy. Conclusion: We have observed significant association of certain factors with increased likelihood of PCU death in advanced cancer patients. These findings need to be validated in a larger prospective study to develop a model predicting PCU mortality for advanced cancer patients. Factor Univariate Analysis Multivariate Analysis OR p OR p Medicare/Medicaid vs. Private or Self pay 0.59 0.044 Age ≥ 65 vs. < 65 0.49 0.010 0.36 0.001 Consultation team referral vs. Emergency Center 2.54 0.114 1.74 0.380 Consultation team referral vs. outpatient center 4.03 0.005 3.93 0.009 Low platelets (<140.000) 2.15 0.003 Low sodium (<135) 1.81 0.021 2.75 0.001 High sodium (>147) 3.67 0.047 3.05 0.110 Low CO2 (<23) 2.29 0.004 High BUN (>20) 1.93 0.014 High heart rate (≥101) 2.07 0.006 High respiratory rate (≥21) 1.88 0.010 1.80 0.036 Supplemental O2 use 2.80 < 0.001 2.35 0.003 Dyspnea * 1.16 0.002 * Not included in the multivariate model. No significant financial relationships to disclose.

Associated and predictive factors of sleep disturbance in advanced cancer patients

Little attention has been paid to sleep disturbance experienced by advanced cancer patients. The purpose of the present study was to investigate longitudinal change in sleep disturbance and to identify factors that associated with and predicted sleep disturbance among 209 consecutive terminally ill cancer patients. Patients were assessed twice for sleep disturbance by one item of the structured clinical interview for assessing depression, once at the time of their registration with a palliative care unit (PCU) (baseline) and again at the time of their PCU admission (follow-up), and possible associated medical and psychosocial factors were evaluated. The proportions of patients with obvious sleep disturbance at baseline and follow-up were 15.3 and 25.9%, respectively. Sixty-seven percent of the subjects showed some sleep status changes, including both aggravation and improvement, between baseline and follow-up. Being younger, having diarrhea and living alone were significantly associated with sleep disturbance at baseline, and the increase of psychological distress was the only significant predictive factor for sleep disturbance at follow-up. These findings suggest that psychological distress is a possible key cause of sleep disturbance and management of psychological distress may be one promising strategy for prevention of sleep disturbance among advanced cancer patients.