Specialist Palliative Care Consultation Research Articles

Validation of Electronic Health Record-Based Algorithms to Identify Specialist Palliative Care Within the Department of Veterans Affairs.

The measurement of specialist palliative care (SPC) across Department of Veterans Affairs (VA) facilities relies on algorithms applied to administrative databases. However, the validity of these algorithms has not been systematically assessed. In a cohort of people with heart failure identified by ICD 9/10 codes, we validated the performance of algorithms to identify SPC consultation in administrative data and differentiate outpatient from inpatient encounters. We derived separate samples of people by receipt of SPC using combinations of stop codes signifying specific clinics, current procedural terminology (CPT), a variable representing encounter location, and ICD-9/ICD-10 codes for SPC. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for each algorithm using chart review as the reference standard. Among 200 people who did and did not receive SPC (mean age=73.9 years (standard deviation [SD]=11.5), 98% male, 73% White), the validity of the stop code plus CPT algorithm to identify any SPC consultation was: Sensitivity=0.89 (95% Confidence Interval [CI] 0.82-0.94), Specificity=1.0 [0.96-1.0], PPV=1.0 [0.96-1.0], NPV=0.93 [0.86-0.97]. The addition of ICD codes increased sensitivity but decreased specificity. Among 200 people who received SPC (mean age=74.2 years [SD=11.8], 99% male, 71% White), algorithm performance in differentiating outpatient from inpatient encounters was: Sensitivity=0.95 (0.88-0.99), Specificity=0.81 (0.72-0.87), PPV=0.38 (0.29-0.49), and NPV=0.99 (0.95-1.0). Adding encounter location improved the sensitivity and specificity of this algorithm. VA algorithms are highly sensitive and specific in identifying SPC and in differentiating outpatient from inpatient encounters. These algorithms can be used with confidence to measure SPC in quality improvement and research across the VA.

783 Consensus Criteria for Palliative Care Consults: A Modified Delphi Approach

Abstract Introduction Specialist palliative care (PC) is a limited resource, best conserved by identifying persons most likely to benefit from a PC consult. Little guidance is available for clinicians on whether/ when to consult PC. The authors previously developed empirically-derived consult criteria to guide burn providers in specialist PC consultation, refining them by expert panel input. Methods A modified three-iteration Delphi process was employed to revise and develop consensus on empirically-derived PC consult criteria in burn patients. Eligible participants (N=202) were identified by (a) having published on burn and PC (b) presented nationally on burn and PC or (c) nomination by the study team as having equivalent expertise in the field. Results Forty-three individuals participated in Iteration 1; n=34 (79%) in Iteration 3, which rank-ordered three versions of criteria and invited further revisions. Consensus eliminated the most parsimonious version. Expert review panelists integrated feedback, yielding a consensus list with 6 criteria for PC consultation and 6 criteria for consideration of PC consult. Consult criteria include patient/family request; conflicted or unclear goals of care; and high modified Baux/SCORTEN scores. Criteria for consideration include no longer meeting milestones; assistance with symptom management; or cardiac arrest. Conclusions Consensus among burn and PC providers enhances validity and supports clinical use to guide burn providers on patients most likely to benefit from specialist PC consultation. Future research should prospectively explore whether adherence to the criteria is associated with improved outcomes and potential further revision. Applicability of Research to Practice Provides guidance on PC consultation and may be used to examine outcomes.

Specialist Palliative Care Consultation for Patients with Nonmalignant Pulmonary Diseases: A Retrospective Study.

Few patients with chronic nonmalignant pulmonary diseases receive specialist palliative care consultation, despite their high symptom burden in end of life. To study palliative care decision making, survival, and hospital resource usage in patients with nonmalignant pulmonary diseases with or without a specialist palliative care consultation. A retrospective chart review of all patients with a chronic nonmalignant pulmonary disease and a palliative care decision (palliative goal of therapy), who were treated in Tampere University Hospital, Finland, between January 1, 2018 and December 31, 2020. A total of 107 patients were included in the study, 62 (58%) had chronic obstructive pulmonary disease (COPD), and 43 (40%) interstitial lung disease (ILD). Median survival after palliative care decision was shorter in patients with ILD than in patients with COPD (59 vs. 213 days, p = 0.004). Involvement of a palliative care specialist in the decision making was not associated with the survival. Patients with COPD who received palliative care consultation visited less often emergency room (73% vs. 100%, p = 0.019) and spent fewer days in the hospital (7 vs. 18 days, p = 0.007) during the last year of life. When a palliative care specialist attended the decision making, the presence and opinions of the patients were recorded more often, and the patients were more frequently referred to a palliative care pathway. Specialist palliative care consultation seems to enable better end-of-life care and supports shared decision making for patients with nonmalignant pulmonary diseases. Therefore, palliative care consultations should be utilized in nonmalignant pulmonary diseases preferably before the last days of life.

Clinicians' views on the use of triggers for specialist palliative care in the ICU: A qualitative secondary analysis.

To understand clinicians' views regarding use of clinical criteria, or triggers, for specialist palliative care consultation in the ICU. Secondary analysis of a qualitative study that explored factors associated with adoption of specialist palliative care in the ICU. Semi-structured interviews with 36 ICU and palliative care clinicians included questions related to triggers for specialist palliative care. We performed a thematic analysis to identify participants' views on use of triggers, including appropriateness of cases for specialists and issues surrounding trigger implementation. We identified five major themes: 1) Appropriate triggers for specialist palliative care, 2) Issues leading to clinician ambivalence for triggers, 3) Prospective buy-in of stakeholders, 4) Workflow considerations in deploying a trigger system, and 5) Role of ICU clinicians in approving specialist palliative care consults. Appropriate triggers included end-of-life care, chronic critical illness, frequent ICU admissions, and patient/family support. Most clinicians had concerns about "trigger overload" and ICU clinicians wanted to be broadly involved in implementation efforts. ICU and palliative care clinicians identified important issues to consider when implementing triggers for specialist palliative care consultation. Future research is needed to longitudinally examine the most appropriate triggers and best practices for trigger implementation.

EP10.01-008 Examining Social Determinants of Health Among Newly Diagnosed Lung Cancer Patients Contacted for Early Specialist Palliative Care Consultation

Timely palliative care interventions can help to alleviate the distress people experience after diagnosis of an incurable, life-threatening cancer. However, referrals to palliative care are often late and inequities have been described across sociodemographic groups. The Palliative Care Early and Systematic (PaCES)-Automatic study was co-designed with patients and providers. It provides an automatic early palliative care intervention triggered by pre-determined clinical criteria, without the need for formal clinician referral, for automatically offering an early supportive and palliative care (SPC) consultation to all patients newly diagnosed with stage IV non-small cell lung cancer (NSCLC).

Palliative care utilization, transfusion burden, and end-of-life care for patients with multiple myeloma.

Despite treatment advances, multiple myeloma (MM) remains a significant source of morbidity and mortality. We aimed to examine specialist palliative care (SPC) involvement and end-of-life care for patients with MM. We assessed all deceased patients with a diagnosis of MM who received care at a single institution from January 2010 to December 2019 and assessed SPC involvement. We reviewed 456 deceased patients. Overall, 207 patients (45.4%) received SPC visits by clinicians during their disease, and 153 (33.5%) were on MM treatment in the month before death. Median time from SPC consultation to death was 1 month, with 42 (9.2%) of patients receiving SPC visits 6 or more months before death. Amongst the patients for which a place of death was reported (351), 117 (33.3%) died in the acute care setting. Outpatient SPC did not correlate with a reduction of death in the acute care setting. In the group of patients who received outpatient SPC, 22/84 (26.2%) died in an acute care setting, whereas 95/267 (35.5%) patients who did not receive outpatient SPC also died in an acute care setting, (p= .11). In our analysis of the entire trajectory of the MM patient experience from diagnosis to death, we found low rates of SPC involvement and a significant proportion of patients receiving aggressive care at end-of-life. While there is no clear correlation that SPC involvement impacted the rate of acute care deaths or decreased utilization of MM treatment in the last month of life, further prospective research on optimal utilization of SPC is required.

Triggers for Specialist Palliative Care Consultation in the ICU: A Qualitative Secondary Analysis (S562)

Triggers for Specialist Palliative Care Consultation in the ICU: A Qualitative Secondary Analysis (S562)

Patient & Caregiver Experiences: Qualitative Study Comparison Before and After Implementation of Early Palliative Care for Advanced Colorectal Cancer.

The Palliative Care Early and Systematic (PaCES) program implemented an early palliative care pathway for advanced colorectal cancer patients in January 2019, to increase specialist palliative care consultation and palliative homecare referrals more than three months before death. This study aimed to understand the experience of patients with advanced colorectal cancer and family caregivers who received early palliative care supports from a specialist palliative care nurse and compared those experiences with participants who experienced standard oncology care prior to implementation of early palliative care. This was a qualitative and patient-oriented study. We conducted semi-structured telephone interviews with two cohorts of patients with advanced colorectal cancer before and after implementation of an early palliative care pathway. We conducted a thematic analysis of the transcripts guided by a Person-Centred Care Framework. Seven patients living with advanced colorectal cancer and five family caregivers who received early palliative care supports expressed that visits from their early palliative care nurse was helpful, improved their understanding of palliative care, and improved their care. Four main themes shaped their experience of early palliative care: care coordination, perception of palliative care & advance care planning, coping with advanced cancer, and patient and family engagement. These findings were compared with experiences of 15 patients and seven caregivers prior to pathway implementation. An early palliative care pathway can improve advanced cancer care, and improve understanding and acceptance of early palliative care. This work was conducted in the context of colorectal cancer but may have relevance for the care of other advanced cancers.

Palliative radiotherapy delivery by a dedicated multidisciplinary team facilitates early integration of palliative care: A secondary analysis of routinely collected health data

BackgroundEarly integration of Specialist Palliative Care (SPC) with oncological care improves quality of life (QOL) of patients with advanced cancer; however, patients tend to access SPC late in their disease trajectory, if at all. Routine referral of all patients to SPC would quickly overwhelm available resources, suggesting a need for widespread accessibility of generalist PC competencies. This has been increasingly facilitated by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at the Cross Cancer Institute (CCI). Our objectives were to estimate the proportion of patients dying with breast cancer seen in consultation for PRT, and the interaction between PRT delivery and SPC referral. MethodsThis secondary analysis of routinely collected health data examined female adults with breast cancer who died between 04/01/2013 and 03/31/2014, and had advanced disease while under the care of a CCI oncologist. Alberta Cancer Registry, electronic medical records, and Edmonton Zone Palliative Care Program data were linked. During the study period, referrals for SPC, and setting of assessment for PRT, were at the attending physicians’ discretion. Clinical data were abstracted including summaries of intervals between PRT and SPC consultations, as well as from consults to death. Kaplan-Meier survival estimates, independent samples median tests, t tests of proportions, independent t tests and Chi-square tests compared groups. ResultsOf 194 patients, median age at cancer diagnosis was 59 years (range 24-95yrs), median one-way distance from the CCI was 18.8km, and overall median survival (MS) was 4.4 years. 130/194 (67.0%) and 110/194 (56.7%) were assessed for PRT and by SPC respectively; 22/194 (11.3%) saw neither prior to death. Median time between first PRT consultation and death was 11.7 months (interquartile range 3.7-22.2 mos). Median time between first SPC consult and death was 2.9 mos (IQR 1-6.2 mos). 65.6% of those who never had PRT ultimately required SPC involvement, versus 52.3% of those receiving PRT. Of the 68/130 who had both, 91.2% were seen for PRT first, a median of 7.9 mos prior to seeing SPC. Patients who had SPC consultation without previous PRT were seen by PC a median 1.5 mos prior to death (IQR 0.6-4.9 mos). Patients seen for PRT outside of the PRO clinic had SPC consultation a median of 3.3 mos before death (IQR 1.2-6.2 mos), versus those seen by the PRO clinic team, who were referred a median of 6.2 mos prior (IQR 2.4-8.1 mos). ConclusionsFewer advanced breast cancer patients who received PRT ultimately required SPC consultation, but those who did were referred earlier in their disease course, especially if PRT assessment and delivery had taken place in the setting of a dedicated multidisciplinary team.

Prevalence and timing of specialist palliative care access among advanced cancer patients and association with hospital death

BackgroundPatients with advanced cancer have poor quality of life and high utilisation of acute healthcare services. Early access to palliative care has been shown to improve quality of life as well as reduce acute healthcare utilisation and costs.ObjectivesTo determine the prevalence and timing of hospital-based specialist palliative care reviews for patients with advanced cancer known to National Cancer Centre Singapore. We also explored the association between specialist palliative care review and place of death.MethodsA retrospective study of patients with Stage 4 cancer who died in a 2-year period from 1 January 2016 to 31 December 2017 (regardless of their date of diagnosis) and who received treatment in National Cancer Centre Singapore (NCCS).ResultsA total of 2572 patients were included, of which 1226 (47.7%) had at least one inpatient or outpatient specialist palliative care consultation. Those who had their first specialist palliative care review 30 days or less before death had a 2.01 (95% CI 1.62 to 2.49, p < 0.001) increased odds of hospital death while those who had the first hospital-based palliative care review more than 30 days before death a 0.76 (95% CI 0.62 to 0.93, p = 0.009) reduced odds of hospital death.ConclusionsOur study found inadequate and late access to specialist palliative care among advanced cancer patients. Furthermore, late access to specialist palliative care was associated with hospital death. There is an urgent need to improve access to specialist palliative care in order to improve patient outcomes.

Palliative Radiotherapy Delivery by a Dedicated Multidisciplinary Supportive Care Team: Facilitating Early Integration of Palliative Care for Patients With Breast Cancer

Despite level one evidence that early integration of specialist palliative care (SPC) improves quality of life, patients tend to access SPC late in their disease trajectory, if at all. Widespread accessibility of generalist PC competencies has been increasingly provided by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at our institute. We evaluated the interaction between PRT delivery and need for SPC referral.This secondary analysis of routinely collected health data examined adult female patients with breast cancer, deceased between 04/01/2013 and 03/31/2014. Alberta Cancer Registry, electronic medical records, and Palliative Care Program data were linked. Referrals for PRT and SPC were at the attending physicians' discretion. Clinical data were abstracted including intervals between PRT and SPC consultations. Summary statistics were calculated and independent samples median tests were used for comparison.Of our study cohort of 194 patients, 130 (67.0%) had at least one PRT consult, and 111 (57.2%) were assessed by SPC. First PRT and SPC consultations occurred a median of 11.5 months (interquartile range 3.6-22.1 mos) and 2.8 mos (IQR 0.9 -6.1 mos) before death, respectively. 65.6% (42/64) of those who never had PRT received SPC involvement, versus 53.1% (69/130) of those receiving PRT consult. In the absence of previous PRT, patients had SPC consultation a median of 1.5 mos prior to death (IQR 0.6-4.9 mos); those who had PRT first were seen by SPC a median of 3.3 mos prior (IQR 1.2-6.4 mos) (P = 0.08). Patients seen for PRT outside versus within the PRO clinic had SPC consultation a median of 3.2 mos (IQR 1.2-6.1 mos) versus 5.5 mos prior to death (IQR 2.3-7.1 mos), respectively (P = 0.95).Fewer advanced breast cancer patients who underwent PRT ultimately required SPC consultation, but those who did trended towards referral earlier in their disease course, especially if PRT delivery took place in the setting of a dedicated multidisciplinary team.

Oncology Clinicians' Challenges to Providing Palliative Cancer Care-A Theoretical Domains Framework, Pan-Cancer System Survey.

Despite the known benefits, healthcare systems struggle to provide early, integrated palliative care (PC) for advanced cancer patients. Understanding the barriers to providing PC from the perspective of oncology clinicians is an important first step in improving care. A 33-item online survey was emailed to all oncology clinicians working with all cancer types in Alberta, Canada, from November 2017 to January 2018. Questions were informed by Michie’s Theoretical Domains Framework and Behaviour Change Wheel (BCW) and queried (a) PC provision in oncology clinics, (b) specialist PC consultation referrals, and (c) working with PC consultants and home care. Respondents (n = 263) were nurses (41%), physicians (25%), and allied healthcare professionals (18%). Barriers most frequently identified were “clinicians’ limited time/competing priorities” (64%), “patients’ negative perceptions of PC” (63%), and clinicians’ capability to manage patients’ social issues (63%). These factors mapped to all three BCW domains: motivation, opportunity, and capability. In contrast, the least frequently identified barriers were clinician motivation and perceived PC benefits. Oncology clinicians’ perceptions of barriers to early PC were comparable across tumour types and specialties but varied by professional role. The main challenges to early integrated PC include all three BCW domains. Notably, motivation is not a barrier for oncology clinicians; however, opportunity and capability barriers were identified. Multifaceted interventions using these findings have been developed, such as tip sheets to enhance capability, reframing PC with patients, and earlier specialist PC nursing access, to enhance clinicians’ use of and patients’ benefits from an early PC approach.

Specialist Palliative Care Activity at an Acute Care Tertiary Hospital and Its Representation in Administrative Data.

To quantify and examine specialist palliative care (SPC) in-hospital activity and compare it to routinely collected administrative data on palliative care (PC). All patients discharged from a large acute care tertiary hospital in New South Wales, Australia, between July 1 and December 31, 2017, were identified from the hospital's data warehouse. Administrative data were supplemented with information from the electronic medical record for hospital stays which were assigned the PC additional diagnosis code (Z51.5); had a "palliative care" care type; or included SPC consultation. Of 34 653 hospital stays, 524 were coded as receiving PC-based on care type (43%) and/or diagnosis code Z51.5 (100%). Specialist palliative care provided 1717 consultations over 507 hospital stays. Patients had 2 (median; interquartile range: 1-4) consultations during an average stay of 15.3 days (SD 15.78; median 10); the first occurred 7.0 days (SD 12.13; median 3) after admission. Of patient stays with an SPC consultation, 70% were assigned the PC Z51.5 code; 60% were referred for symptom management; 68% had cancer. One hundred forty-one patients were under a palliative specialist-either from initial hospital admission (49.6%) or later in their stay. Palliative care specialists provide expert input into patient management, benefitting patients and other clinicians. Administrative data inadequately capture their involvement in patient care, especially consultations, and are therefore inappropriate for reporting SPC activity. Exclusion of information related to SPC activity results in an incomplete and distorted representation of PC services and fails to acknowledge the valuable contribution made by SPC.

A randomized trial of a specialist palliative care intervention for patients undergoing surgery for cancer: rationale and design of the Surgery for Cancer with Option of Palliative Care Expert (SCOPE) Trial

BackgroundIn medical oncology settings, early specialist palliative care interventions have demonstrated improvements in patient quality of life and survival compared with usual oncologic care. However, the effect of early specialist palliative care interventions in surgical oncology settings is not well studied.MethodsThe Surgery for Cancer with Option for Palliative Care Expert (SCOPE) Trial is a single-center, prospective, single-blind, randomized controlled trial of a specialist palliative care intervention for cancer patients undergoing non-palliative surgery. It will enroll 236 patients scheduled for major abdominal operations for malignancy, who will be randomized 1:1 at enrollment to receive usual care (control arm) or specialist palliative care consultation (intervention arm). Intervention arm patients will receive consultations from a palliative care specialist (physician or nurse practitioner) preoperatively and postoperatively. The primary outcome is physical and functional wellbeing at 90 days postoperatively. Secondary outcomes are quality of life at 90 days postoperatively, posttraumatic stress disorder symptoms at 180 days postoperatively, days alive at home without an emergency room visit in the first 90 postoperative days, and overall survival at 1 year postoperatively. Participants will be followed for 3 years after surgery for exploratory analyses of their ongoing quality of life, healthcare utilization, and mortality.DiscussionSCOPE is an ongoing randomized controlled trial evaluating specialist palliative care interventions for cancer patients undergoing non-palliative oncologic surgery. Findings from the study will inform ways to identify and improve care of surgical patients who will likely benefit from specialist palliative care services.Trial registrationClinicalTrials.gov Identifier: NCT03436290First Registered: 16 February 2018Enrollment Began: 1 March 2018Last Update: 20 December 2018

Attitudes of Liver and Palliative Care Clinicians toward Specialist Palliative Care Consultation for Patients with End-Stage Liver Disease.

Objective: Delays in specialized palliative care (PC) consultation in end-stage liver disease (ESLD) patients may be explained by clinician attitudes toward PC. Our aim is to assess the attitudes of hepatology and liver transplant (HLT) and PC clinicians toward PC consultation and consultant roles in ESLD patient care. Methods: Clinician members of HLT and PC professional societies were surveyed. Using a five-point Likert scale, they rated their comfort level toward various PC consultant roles and their agreement with triggers for and reasons to defer PC consultation. Change in attitudes toward PC consultation resulting from liver transplant (LT) eligibility was evaluated. Results: A total of 311 HLT (6.2%) and 379 PC (8.1%) clinicians completed the survey. The vast majority of HLT clinicians (>80%) were comfortable if PC consultants palliate symptoms, provide support, or facilitate advance care planning in LT-ineligible patients. LT eligibility reduced HLT clinician comfort toward all PC consultant roles, except supportive care. A vast majority of PC clinicians (>90%) were comfortable assuming all PC roles, except pain management without opioids (43-51%). About 80% of HLT clinicians agree with PC consultation in LT-ineligible patients with decompensated cirrhosis or hepatocellular carcinoma (HCC), compared to 20-30% if LT ineligible. Common justifications for deferring PC consultation included mild disease, LT eligibility, unavailability of PC specialists, and lack of addressable palliative issues. Conclusions: Barriers to specialized PC consultation in ESLD include HLT clinician discomfort with PC consultant roles, patients' LT eligibility, perception that PC is end-of-life care, unclear triggers for PC consultation, and concern about opioid-based pain palliation.

Barriers to providing palliative care to patients with advanced cancer: A province-wide survey of oncology clinicians’ perceptions.

88 Background: Despite known benefits, cancer care systems struggle to provide early, integrated palliative care (PC). Previously, we identified barriers to providing early PC as perceived by gastrointestinal oncology clinicians in Alberta, Canada (top barrier: time/competing priorities). Here, we expand on the previous study to better understand barriers to early PC for clinicians working with all tumor groups across Alberta. Methods: A 33-item survey was emailed to oncology clinicians in Alberta between November 2017 - January 2018. Questions were informed by Michie’s Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW) and queried (a) providing PC in oncology clinics, (b) referral to specialist PC consultation, and (c) working with PC consultants and homecare. Results: Respondents (n = 268) were nurses (42%), physicians (25%), and allied health professionals (20%). Barriers most frequently identified were "patients’ negative perceptions of PC” (68%), “my limited time/competing priorities” (66%), and "capability to manage patients’", social (65%) and spiritual (63%) concerns. These factors map to all three BCW domains: motivation, opportunity, and capability. In contrast, least frequently identified barriers were in clinician’s own motivation, e.g. perceived benefits of PC. There were few significant differences in response by tumor group or profession (χ2 test, responses coded: disagree [1-3], neutral [4], agree [5-7]). Most notably, tumor groups differed in their perception that “the criteria for PC services are too restrictive” (p = 0.003), while nurses and allied staff reported that patients’ negative perception of PC is a barrier more frequently than physicians (p = 0.003). Conclusions: Surveying across clinicians and tumor groups using Michie’s TDF/BCW revealed that the challenges to an early integrated PC approach include all three sources of behavior, though not equally for all clinicians. Determining this has allowed us to tailor multifaceted interventions, e.g. tip sheets to enhance capability, re-framing PC with patients, and earlier secondary PC nursing access, to enhance clinicians use and patients benefit from an early PC approach.

Effect of Speciallist Palliative Care Service on End-of Life Care in Patients with Hematologic Malignancies

Previous research demonstrated that patients with hematologic malignancies have a high probability receiving intensive care at their end-of-life (EOL). In this study, we assessed EOL quality measures in patients with hematologic malignancies before and after starting the provision of a specialist palliative care service.We conducted a retrospective cohort study in Komaki City Hospital. Provision of the specialist palliative care service was started in our hospital on April 1, 2012. We reviewed the medical records of all adult patients who died of hematologic malignancies between April 1, 2007 and March 31, 2017. Patients who had been cared for in the Departments of Hematology and Palliative Care were included. This study was approved by the institutional review board of Komaki City Hospital. We assessed the prevalence and trends of multiple measures of intensive EOL care established in the peer-reviewed literature. Intensive EOL care was defined as the occurrence of at least one of the following acts: 1) cardiopulmonary resuscitation (CPR) in the last 30 days of life, 2) intubation in the last 30 days of life, 3) intensive care unit (ICU) admission in the last 30 days of life, 4) chemotherapy use within the last 14 days of life, 5) receiving red cell transfusions within the 7 days before death, and 6) receiving platelet transfusion within the 7 days before death. Analysis of frequencies was performed using Fisher's exact test for 2 x 2 tables. The Cochran-Armitage test was used to test for trends over time.A total of 351 consecutive patients who died from hematologic malignancies were identified: 176 before and 175 after April 1, 2012. The median age at death was 73 years old. These included 150 patients with non-Hodgkin lymphoma, 113 with acute myeloid leukemia, 63 with multiple myeloma, 11 with acute lymphoblastic leukemia, 8 with chronic lymphocytic leukemia, and 5 with Hodgkin lymphoma. A total of 69 (39%) received specialist palliative care consultation and 24 (14%) died in the palliative care unit (PCU) after April 2012. Deaths in the PCU increased from 1 (2%) in 2012 to 8 (27%) in 2016 (P for trend <0.001). The median time from palliative care referral to death was 26 days (interquartile range [IQR]: 10-49 days). The length of stay in the PCU was 16 days (IQR: 9.5-22.5 days).Cases of CPR in the last 30 days of life decreased from 4 (13%) in 2007 to 0 in 2016 (P for trend <0.001). Intubations in the last 30 days of life also decreased from 2 (6%) in 2007 to 1 (3%) in 2016 (P for trend 0.046). Platelet transfusions within 7 days before death decreased from 18 (56%) in 2007 to 14 (47%) in 2016 (P for trend 0.031). There were no significant decreases in ICU admissions in the last 30 days of life, chemotherapy use within the last 14 days of life, or receiving red cell transfusions within 7 days before death from 2007 to 2016. Patients receiving at least one act of intensive EOL care significantly decreased from 23 (72%) in 2007 to 19 (63%) in 2016 (P for trend 0.019).Compared with patients with acute leukemia (AL), those with malignant lymphoma (ML) were more likely to receive specialist palliative care consultation (49% vs. 27%, respectively; P=0.010) and die in the PCU (21% vs. 5%, respectively; P=0.007). In patients with ML, deaths in the PCU increased from 1 (5%) in 2012 to 7 (50%) in 2016 (P for trend <0.001).In patients with ML, cases of chemotherapy use within the last 14 days of life decreased from 5 (22%) in 2007 to 2 (14%) in 2016 (P for trend 0.030). Patients with ML who received palliative care consultation were less likely to receive platelet transfusion within 7 days before death compared with those who did not (28% vs. 51%, respectively; P=0.041). In patients with ML, those receiving at least one act of intensive EOL care significantly decreased from 11 (65%) in 2007 to 5 (35%) in 2016 (P for trend <0.001). In patients with AL, there was no significant difference in chemotherapy use within the last 14 days of life or receiving transfusions within 7 days before death between patients who received specialist palliative care and those who did not. All patients with AL received at least one act of intensive EOL care in 2016.These findings suggest that specialist palliative care improved the quality of EOL care in patients with hematologic malignancies, especially in those with ML. However, in patients with AL, EOL care is still suboptimal with the provision of specialist palliative care. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Evidence-based Management of Cancer Pain.

To provide a brief review of common palliative care practices in the assessment and management of cancer pain for practicing oncology nurses. Published literature as indexed in Medline, relevant guideline documents, textbooks, and clinical experience. All persons with cancer should undergo a comprehensive pain assessment, using validated instruments when possible, and receive expert-guided cancer pain therapy. Specialist palliative care consultation should be engaged as needed to provide an extra layer of support. By better understanding cancer pain assessment and management strategies, nurses will be best equipped to meet the needs of patients and families.

Validation of the ICD-9 Diagnostic Code for Palliative Care in Patients Hospitalized With Heart Failure Within the Veterans Health Administration.

Patients with heart failure (HF) are at increased risk of unmet palliative care needs. The International Classification of Diseases, Ninth Revision ( ICD-9) code, V66.7, can identify palliative care services. However, code validity for specialist palliative care in the Veterans Health Administration (VHA) has not been determined. To validate the ICD-9 code for specialist palliative care and determine common reasons for specialist palliative care consultation among VHA patients hospitalized with HF. Electronic health record review of data from the Veterans Aging Cohort Study. The sample included 100 patients hospitalized with HF from 2003 to 2012. Data from 50 patients with V66.7 were matched by age, race, site of care, hospital length of stay, intensive care unit admission, and fiscal year of study discharge to 50 patients with HF without V66.7 who had died within a year of hospitalization. We calculated positive and negative predictive values (PPV, NPV), sensitivity, and specificity. All patients included in the sample were male, 66% black ethnicity, and mean age = 65 years (standard deviations [SD] ± 10.5 for cases; SD ± 9.8 for matches). Specialist palliative care was documented for 49 of 50 patients with V66.7 (PPV = 98%, 95% confidence interval [CI]: 88-99) and 9 of 50 patients without the code (NPV = 82%, 95% CI: 68-91). Sensitivity was 84% (95% CI: 72-92), and specificity was 98% (95% CI: 86-99). Establishing goals of care was the most frequent reason for palliative care consultation (43% of the sample). The ICD-9 code V66.7 identifies specialist palliative care for hospitalized patients with HF in the VHA. Replication of findings in other data sources and populations is needed.

Early specialist palliative care for all hospitalized advanced cancer patients (ACP)? Effect of “up-front” versus “on demand” palliative care on outcomes.

172 Background: Palliative care improves outcomes for cancer patients, especially those with advanced disease. Optimal timing for initiation of specialist palliative care remains undetermined. We created a Supportive Oncology inpatient service that integrates immediate “up-front” palliative care (IPC) consultation for selected ACP to supplement our usual oncologic care (UOC) service, which continued to utilize “on-demand” palliative care consultation. Here, we compare ACP populations and selected outcomes between these two versions of in-patient cancer care. Methods: A retrospective cohort analysis of ACP receiving either IPC or UOC between Jan 2015-Dec 2015 (N=809). ACP were compared for age, gender, race, and ethnicity. Disease severity was determined by APR DRG weight, Risk of Mortality (ROM), and Severity score. Outcomes included examining differences between groups for: Length of stay (LOS), Cost, and 30 day readmission rate. Univariate and multivariate analysis were employed. Results: 468 ACP were admitted to IPC and 341 to UOC. Compared with UOC, ACP assigned to IPC were significantly younger (61.1±13.2 vs 63.3±13.0, p=0.02); more likely female (50% vs 40%, P=0.005); and more likely to be AA (47% vs 35%, P=0.005). After adjusting for gender, age, race, and encounter type, ACP receiving IPC had higher ROM (52% v 47%, p=0.03). There were no differences in APR DRG weight (p=0.30) or Severity scores (p=0.34). IPC had significantly lower costs ($12,050 vs $15,990, p=0.003), less 30-day readmissions (16% vs 23%, p=0.03), and a trend toward shorter LOS (5.6 ± 4.9 vs 6.2 ± 6.5, p=0.10). Hospice referral and survival data will be presented. Conclusions: Our data provides additional evidence for the benefits of earlier specialist palliative care consultation services, including patients traditionally identified as underserved.