Terminal Admission Research Articles

Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions

ContextLittle is known about Veterans who die during a short terminal admission, which renders them ineligible for the Department of Veterans Affairs (VA) Bereaved Family Survey. ObjectivesWe sought to describe this population and identify opportunities to improve end-of-life (EOL) care quality. MethodsRetrospective, cohort analysis of Veteran decedents who died in a VA inpatient setting between October 2018-September 2019. Veterans were dichotomized by short (<24 hours) and long (≥24 hours) terminal admissions; sociodemographics, clinical characteristics, VA and non-VA healthcare use, and EOL care quality indicators were compared. ResultsAmong 17,033 inpatient decedents, 723 (4%) had short terminal admissions. Patients with short compared to long terminal admissions were less likely to have a VA hospitalization (38% vs. 54%) in the last 90 days of life and were more likely to die in an intensive care (49% vs 21%) or acute care (27% vs 18%) unit. Patients with a short compared to long admission were about half as likely to receive hospice (33% vs 64%) or palliative care (33% vs 69%). Most patients with short admissions (76%) had a life-limiting condition (e.g., cancer, chronic obstructive pulmonary disease) and those with cancer were more likely to receive palliative care compared to those with non-cancer conditions. ConclusionVeterans with short terminal admissions are less likely to receive hospice or palliative care compared to patients with long terminal admissions. Many patients with short terminal admissions, such as those with life-limiting conditions (especially cancer), receive aspects of high-quality EOL care, however, opportunities for improvement exist.

Procedural Interventions for Terminally Ill Children - Are We Aiding Palliation?

Objectives: Many children undergo surgery or an invasive procedure during their terminal hospital admission.1 The types of procedures, patients, and the intent of the procedures has not been well defined. Understanding these details may help pediatric surgeons better determine the clinical settings in which certain procedures will not enhance palliation or survival. Methods: A retrospective single institution chart review was performed for patients age 14 days to 18 years with chronic conditions who died while inpatient from 2013-2017. Data was gathered on demographics, primary diagnosis, intubation status, palliative care involvement, duration of hospital stay, length of palliative care involvement, and total number of procedures. Negative binomial regression was used to assess association with number of procedures. Results: 132 children met inclusion criteria. Most children were White and less than one year old. The most common type of diagnosis was cardiac in nature. Children underwent an average of three procedures. 75% were intubated and 77.5% had palliative care involved. Patients who were less than one year old at death were more likely to have been intubated, had longer terminal hospital stays, and had more procedures. Those who were intubated underwent more procedures and had longer hospital stays. Those with longer palliative care involvement had fewer procedures. Conclusions: Children undergo a significant number of surgical procedures during their terminal hospitalization. This may be influenced by age, intubation status, and length of stay. Ongoing study may help refine which procedures may have limited impact on survival in the chronically ill pediatric population.

Multi-center study on mortality in children, and adults with sickle cell anemia-risk factors and causes of death

Sickle cell disease (SCD) is a major public health burden worldwide with increasing morbidity and mortality. The study evaluates the risk factors associated with mortality in SCD patients, between the years 2006 and 2020 at three hospitals in Oman. The analysis includes clinical manifestations, haematological, biochemical, and radiological parameters, use of antibiotics, and blood and exchange transfusions. Our cohort included 123 patients (82 males, 41 females), with a median age of 27 (Interquartile Range 21–35 years). SCD related complications included acute chest syndrome (ACS) in 52.8%, splenic sequestration in 21.1%, right upper quadrant syndrome in 19.5%, more than > 6 VOC/year in 17.9%, and stroke in 13.8%. At the terminal admission, patients had cough, reduced O2 saturation, crepitation and fever in 24.4%, 49.6%, 53.6% and 68.3% respectively. Abnormal chest X-ray and chest CT scan were seen in 57.7%, and 76.4% respectively. Laboratory parameters showed a significant drop in hemoglobin (Hb) and platelet counts from baseline, with a significant rise in WBC, LDH and CRP from baseline (p < 0.05, Wilcoxon Signed Ranks test). All patients received antibiotics, whereas, 95.9% and 93.5% received simple blood transfusions, and exchange transfusions respectively, and 66.6% required non-invasive ventilation. Among the causes of death, ACS is seen in 32 (26%), sepsis in 49 (40%), and miscellaneous in 42 (34%). Sudden death was seen in 32 (26%) of patients. Male gender, with low HbF, rapid drop in Hb and platelet, and increased in WBC, LDH, ferritin, and CRP, correlated significantly with mortality in this cohort.

Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents

ContextDespite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. ObjectivesTo compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. MethodsIn this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. ResultsWe identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99–3.40) and DNI completion (OR 1.81; 95%CI, 1.07–1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55–1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03–41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). ConclusionsDuring terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.

Heart failure and the cost of dying: must the ferryman always be paid?

Provision of palliative care in chronic heart failure (CHF) can support complex decision-making, significantly improve quality of life and may lower healthcare costs. To examine whether healthcare costs differed in terminal admissions according to the adoption of a palliative approach. Retrospective review of medical records and costing data for all admissions resulting in death from CHF (July 2011 to December 2019),analysed as two groups (2011-2016 and 2016-2019) because of background changes in costings. Admissions with CHF resulting in death in an Australian tertiary referral centre. The cohort (n = 439) were elderly (median age 83.7 years, interquartile range (IQR) = 77.6-88.7 years) and mostly men (54.9%). Half (230, 52.4%) were referred to a specialist palliative care team, whereas over a third (172, 39.2%) received a palliative approach. Receiving a palliative approach was associated with a nonstatistically significant lower admission cost (AU$12 710 vs AU$15 978; P = 0.19) between 2011 and 2016 (n = 101, 38.8%) and a significantly lower cost (AU$11 319 vs AU$15 978; P < 0.01) between 2016 and 2019 (n = 71, 39.7%). Intensive care admission resulted in the single greatest additional cost at AU$14 624 (IQR = AU$4130-AU$44 197) (n = 48, 2011-2016). Median terminal admission cost was lower for patients with comfort goals of care (P < 0.01), without life-sustaining interventions (P < 0.01) or who received a palliative approach (P < 0.01). Referral to inpatient specialist palliative care or receiving a palliative approach resulted in comparable admission costings (AU$11 621 [IQR = AU$4705-AU$32 457] and AU$11 466 [IQR = AU$4973-AU$25 614]). A palliative approach in terminal CHF admission may improve quality at the end of life and decrease costs associated with care.

Palliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit

Introduction/AimDespite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. MethodsMultisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. ResultsOf 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. “Not-for-resuscitation” orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001). ConclusionsEnd-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.

Code Status Discussions in Pediatric Patients With Heart Disease During Terminal Admissions.

Code Status Discussions in Pediatric Patients With Heart Disease During Terminal Admissions.

Longitudinal changes in patient reported outcome measures in patients with cancer six months prior to death: A case-control study.

1585 Background: Provider assessments consistently fall short in determining when cancer patients enter into the terminal phase of their disease. Despite prior desires to spend their last days outside an institution, patients often seek emergency room care and most report never having a palliative consultation at the time of their terminal admission. Patient reported outcome measures (PROMs) are derived directly from the patient and may provide insight into the experience near the end of life to facilitate earlier involvement of supportive oncology. This study aims to compare PROMs in the 6 months prior to death to those not dying among patients with cancer. Methods: This study uses a routine PROMs program implemented since September 2020 for all patients with a cancer diagnosis at a tertiary care hospital. This study focused on PROMs using 3 domains of the Patient Reported Outcomes Measurement Information System (PROMIS): physical function, pain interference, and fatigue; PROMs frequency mirrored patients’ oncologic visits. Using a retrospective case-control study, patients who had died within 6 months of a PROMs response (cases) were compared to controls who were alive at the time of the case’s death. Cases were matched 1:2 to controls by age at PROMs completion, gender, cancer disease site, and stage. Generalized estimating equation (GEE) models adjusted for age at PROMs completion, gender, cancer disease site, stage, and correlations between individual patient encounters were used to compare mean PROMs scores between cases and controls in each domain. Results: In total, 274 cases were compared to 270 unique controls. Univariate comparisons between cases and controls demonstrated significant differences only in Charlson Comorbidity Index (CCI), with cases demonstrating worse CCI (3.3 ± 2.5) compared to controls (2.3 ±2.2; p &lt; 0.001). Time from diagnosis to PROMs completion was not different between groups (4.08 versus 4.10 years, p = 0.798). Over the 6 months prior to death, 10.5%/15.0%/32.0% cases had severe pain/fatigue/physical function scores compared to 3.3%/3.7%.8.7% in controls (p &lt; 0.001). GEE models demonstrated that cases had a higher mean fatigue score of 5.34 points (95% CI = 3.81 to 6.88), higher mean pain interference score of 4.92 points (95% CI = 3.42 to 6.43), and lower mean physical function score of 7.39 points (95% CI = -8.84 to -5.93) indicating more severe symptom scores for cases in all three domains. Conclusions: On average, patients experiencing death within 6 months of PROMs completion demonstrated worse physical functioning, pain interference, and fatigue scores compared to their age, gender, cancer disease site, and stage matched controls. The differences in PROMs scores represent a first step to improving understanding of PROMs during the terminal stage of disease and may guide indicators for earlier need of supportive oncology support.

Intensity at the end of life in pediatric neuro-oncology patients: The case for pediatric palliative care.

10021 Background: Although pediatric cancer is rare, it is the leading cause of death by disease after infancy for children and adolescents in the United States. Children exist in the context of a family; hence, excellent care for a child must also include attention to the needs of the family. Palliative care aims to enhance quality-of-life for these children living with life threatening illnesses and their families. Among pediatric cancers, brain tumors have high disease-related mortality rates; therefore, early introduction of palliative care to these patients is critical. This study aims to evaluate the association of palliative care during the terminal admissions of pediatric neuro-oncology patients and intensity of care provided at the end of life. Methods: Pediatric patients with brain tumors were identified using the Pediatric Health Information System (PHIS). Inclusion criteria were age &lt;18, diagnosis of brain tumor as defined by ICD-10 codes, discharged as deceased, and hospital admission between 1/1/2017 and 12/31/2021. Intensity of care measures included: pediatric intensive care unit (PICU) admission, mechanical ventilation, total parenteral nutrition (TPN), and extracorporeal membrane oxygenation (ECMO). Results: 567 patients met the inclusion criteria. 359/567 (63%) patients had an inpatient palliative care consultation during their terminal hospital stay. Patients receiving a palliative care consultation had a lower percentage of PICU admission (64.9 vs 83.2, p=&lt;0.001), mechanical ventilation use (51.0 vs 76.0, p=&lt;0.001), and TPN use (18.1 vs 25.5, p=0.027). There were no significant differences in length of stay (22.07 vs 22.25 days, p=0.181) and ECMO use (0.28% vs 1.92%, p=0.450). Conclusions: Pediatric patients receiving palliative care consultations during their terminal admission received less intense care while having comparable lengths of stay. Palliative care should be offered to all families, even with aggressive goals, to help incorporate quality of life and comfort in the treatment plan and to ensure bereavement support is available if needed. Similar to data in the adult palliative care literature, this data demonstrates reduced resource utilization among pediatric patients receiving palliative care. Palliative care has been shown to be a supportive service that has the potential to improve the quality of life of patients. The first step toward equitable healthcare is to ensure that all children with a potentially terminal cancer diagnosis have access to full supportive services, including palliative care.

Operating on Borrowed Time: Receipt of Palliative Care by Pediatric Surgical Patients During Terminal Admissions (Sch444)

Operating on Borrowed Time: Receipt of Palliative Care by Pediatric Surgical Patients During Terminal Admissions (Sch444)

Retrospective Study of Thrombosis in Hospitalized Patients with COVID-19 in Rural North Carolina

Background Some patients with COVID-19 develop life-threatening thrombotic complications including myocardial infarction, deep vein thrombosis, pulmonary embolism, disseminated intravascular coagulation, and ischemic stroke. These inflammatory and hypercoagulable states have been well documented in patient cohorts from metropolitan areas, but not in more rural populations, nor has a data-driven treatment plan been developed for thrombotic COVID-19 patients. Methods We undertook a retrospective case-control study of COVID-19-positive patients to analyze the impact of thrombosis on various clinical endpoints including terminal diagnosis and disease severity. Prevalence and impact of thrombosis were determined using medical records from 2237 COVID-19-positive patients hospitalized in Cumberland County, North Carolina. Odds ratios for terminal diagnosis, death, ICU admission, and ventilation were calculated based on thrombosis status, D-dimer level, or type of antithrombotic treatment. Results Terminal diagnosis [OR 1.81; 95% CI (1.10, 2.98)], ICU admission [2.25; (1.33, 3.81)], and ventilation [2.46; (1.45, 4.18)] were all more likely in thrombotic patients (N = 97) compared to nonthrombotic patients (N = 2140) after adjusting for age. D-dimer levels were associated with death overall, but not among thrombotic patients. Treatments that combined antiplatelet and anticoagulant drugs appeared to be more efficacious than anticoagulants alone in preventing death and severe disease. Limitations Patient medical history prior to hospitalization was not evaluated. Conclusion In this cohort, those with thrombosis are at increased risk for adverse outcomes including death and severe disease. Antithrombotic therapy that includes antiplatelet drugs provides improved outcomes. Higher-powered prospective trials will be necessary to confirm any potential merits of antiplatelet therapy.

Relationship Between Palliative Care Consults and Outcomes of Pediatric Surgical Patients During Terminal Admissions.

Background: Pediatric patients often undergo surgery during terminal admissions. However, the involvement and timing of palliative care consults in caring for these patients has not been readily described. Objective: To describe the presence and timing of palliative care consults for pediatric patients who undergo surgical procedures during terminal admissions. Design: Retrospective cohort study using data from the electronic health record. Setting and Participants: Pediatric patients who underwent at least one surgical procedure during a terminal admission at an urban, quaternary hospital in the United States from January 1, 2016 to December 31, 2021. Main Outcomes and Measures: Patients' medical, surgical, and admission-level characteristics were abstracted. Associations were evaluated between these characteristics and the occurrence and timing of a palliative care consult relative to surgery and death. Results: Of 134 patients, 84% received a palliative care consult during their terminal admission. Approximately 36% of consults occurred before surgery, and 12% were within one day of death. Children without a palliative care consult were more likely than children with a consult to die during surgery (19.1% vs. 2.7%, p = 0.02), have surgery within 24 hours of death (52.4% vs. 15.9%, p < 0.001), and undergo a full resuscitation attempt (47.6% vs. 12.4%, p = 0.002). Receipt of a palliative care consultation did not differ by patient sex, reported race and ethnicity, language, insurance, or income level. Conclusions and Relevance: Palliative care consults support high-quality end-of-life care for children and impact perioperative outcomes, including intensity of surgical care and resuscitation in the final hours of life.

Factors Associated With Inpatient Hospice Utilization Among Hospitalized Decedents With Comfort Measures Only Status.

Background: Patients with serious illness may elect to transition their care to comfort measures only (CMO) while in the hospital. Although studies have shown that routine hospice care is underutilized, the rate of general inpatient hospice (GIP) use among CMO patients during their terminal admission remains unclear. Objectives: We sought to (1) examine the rate of GIP utilization and (2) identify factors associated with its use among hospitalized CMO decedents. Methods: CMO decedents in two academic, tertiary care hospitals in the United States who died between October 1, 2020 and October 31, 2021, were subgrouped based on their primary medical service (GIP vs. non-GIP) at the time of inpatient death. Data abstracted from the electronic health record included demographics, primary diagnosis codes, Rothman Index (RI), time of CMO order, ordering clinician type, time of death, and length of stay (LOS). Multivariable logistic regression analysis was performed, adjusting for relevant covariates. Results: Of 1475 CMO decedents, only 321 (n = 22%) patients received GIP. On multivariable analysis, CMO patients who died in an ICU were five times less likely (odds ratio [OR] = 0.18, confidence interval [95% CI] 0.11-0.29) to receive GIP. Every 10-point increase in RI raised the likelihood of receiving GIP by 59% (OR = 1.59, 95% CI 1.39-1.80). Conclusions: Most CMO decedents died in the hospital without GIP. Compared with GIP decedents, non-GIP decedents were less acutely ill. There was no difference in total LOS between the two groups. CMO decedents were much less likely to receive GIP in an ICU. The RI may help clinicians identify CMO patients who would benefit from GIP earlier in their terminal admission.

Abstract 11040: Disparities in Inpatient Intensity of End-of-Life Care for Children With Advanced Heart Disease

Introduction: Children dying of advanced heart disease experience high intensity end-of-life care (EOLC). However, little is known about disparities in EOLC intensity, which is critical for EOLC equity. Methods: We conducted a population-based retrospective analysis using the California Office of Statewide Health Planning and Development private inpatient discharge database to assess disparities in inpatient EOLC intensity by examining the terminal admission for children (0-21y) with cardiomyopathy and moderate/complex congenital heart disease (CHD) who died in 2005-2018. We examined rates of medical intensity (intubation, CPR, etc.) and cardiac intensity (ECMO, ventricular assist device interventions, other cardiac surgeries, or ≥ 2 cardiac catheterization, biopsy, or electrophysiology procedures). Clinical and sociodemographic factors, including death at a California Children’s Services designated cardiac special care center, associated with medical intensity and cardiac intensity were examined. Results: The 2,794 children died and 76% were &lt; 1 year old. Of them, 26% had cardiomyopathy, 44% moderate CHD, and 46% complex CHD. The majority were male (55%) and publicly insured (64%). The largest racial/ethnic group was Hispanic (50%) followed by non-Hispanic white (26%). Mean length of terminal admission was 31±50d, and 82% died at a cardiac special care center. During the terminal admission, the majority (79%) were intubated, 39% had cardiac surgery, 30% received ECMO, 28% received CPR, and 42% had a cardiac intensity marker. Black children and children with cardiomyopathy were less likely to have a cardiac intensity marker (aOR=0.6 [95% CI: 0.39-0.91]; reference, non-Hispanic white, aOR=0.46 [95% CI: 0.34-0.61]; reference, moderate CHD, respectively). Children who died at a cardiac special care center were more likely to have a cardiac intensity marker (aOR=6.79 [95% CI: 4.95-9.32]; reference, non-specialty center). Conclusion: Children with advanced heart disease in California exhibited high intensity EOLC with significant sociodemographic variation. It is critical to determine if this variation represents patient preferences, provider biases, or systemic factors such as resource availability.

The Palliative Approach and Terminal Heart Failure Admissions – Are We Getting it Right?

Chronic heart failure has a high mortality and early provision of palliative care supports complex decision-making and improves quality of life. To explore whether and when a palliative approach was adopted during the last 12 months of life in patients who experienced an in-hospital death from heart failure. Retrospective medical record review of all deaths from chronic heart failure (January 2010 to December 2019). Admissions with chronic heart failure resulting in death were analysed from an Australian tertiary referral centre. The cohort (n=517) were elderly (median age 83.8 years IQR=77.6-88.7) and male (55.1%). Common comorbidities were ischaemic heart disease (n=293 56.7%) and atrial fibrillation (n=289 55.9%). Life sustaining interventions occurred in 97 (18.8%) patients. In 31 (6.0%) patients referral to specialist palliative care occurred prior to, and in 263 (50.9%) during, the terminal admission. Opioids were prescribed to 440 (85.1%) patients. Comfort care was the documented goal in 158 patients (30.6%). A palliative approach was significantly associated with prior admission in the preceding 12 months (OR=1.5 95% CI=1.0-2.1 p<0.043), receiving outpatient care (OR=2.6 95% CI=1.6-4.1 p<0.01), and admissions in the latter half of the decade (OR=1.5 95% CI=1.0-2.0 p<0.038). Despite greater adoption of a palliative approach in the terminal admission over the last decade, a significant proportion of patients receive palliative care late, just prior to death.

High-Intensity End-of-Life Care of Allogeneic Hematopoietic Cell Transplantation Recipients (HCT) — a Population-Based Study

BACKGROUNDIntensity of end-of-life care has received much attention in oncology due to concerns that high intensity care is likely expensive and may be inconsistent with patient goals. For these reasons, the National Quality Forum endorsed quality measures around intensity of end-of-life care for oncology patients and many studies have examined rates of and disparities in intensity of end-of-life care in this population treated with conventional therapy. However, little is known about intensity of end-of-life care in allogeneic HCT recipients, a population that is at very high risk for morbidity and mortality. METHODSUsing the California Office of Statewide Health Planning and Development administrative discharge database linked to death certificates, we performed a population-based analysis of allogeneic HCT recipients who died between 2000-2011 and had received their transplant within one year of death. Previously-defined and validated end-of-life care intensity indicators were used and included an intense medical intervention (CPR, intubation, ICU admission, or hemodialysis) within 30 days of death, discharge and subsequent readmission within 30 days of death, and hospital death. A patient was considered to have a given indicator if it was coded during an admission that took place entirely within 30 days of death and/or coded during a terminal admission. Multivariable logistic regression models were used to evaluate associations between clinical and sociodemographic characteristics and: i) hospital death, ii) any medically-intense intervention, iii) ≥2 intensity indicators, iv) readmission within 30 days of death. Regression analyses were done for the whole group and then stratified by age at death (pediatrics: 0-21y; adolescent and young adult [AYA]: 22-39y; adult: 40+y). Sociodemographic and clinical characteristics were considered associated with high intensity care if they were associated with an intensity indicator in at least 2 of the 4 regression analyses. Estimated costs incurred in the last year of life were calculated using each hospital's charge-to-cost ratio adjusted for 2016 dollars. RESULTSA total of 1978 patients were included in the analysis (390 pediatric, 439 AYA, and 1149 adult) with a median age at death of 40 years old; 57% were non-Hispanic white and 28% were Hispanic; 58% were male; 94% had an oncologic diagnosis (AML [38%]; ALL [22%] were most common). Eighty-four percent of the population died in the hospital, 71% of the patients had ≥2 intensity indicators and 52% had a medically-intense intervention. During their terminal admission or admission within 30 days of death, 48% of the cohort was admitted to the ICU, 44% was intubated, 21% received hemodialysis, and 8% received CPR. Entire Cohort: patient age (15-21y, 30-39y, and 40-49y; referent grp: age >60y) and presence of comorbidities at HCT were associated with a medically-intense intervention, ≥2 interventions, and hospital death. Pediatric Cohort: Presence of ≥2 comorbidities during the admission for HCT was associated with high-intensity end-of-life care (a medically-intense intervention, ≥2 interventions, and hospital death). AYA Cohort: Presence of ≥2 comorbidities during the admission for HCT was associated with high-intensity end-of-life care (a medically-intense intervention, ≥2 interventions, and hospital death). Older Adult Cohort: Patient age (40-49y; referent grp: age >60y) and presence of ≥2 comorbidities at HCT were associated with a medically-intense intervention and >2 intensity indicators. Cost of Care: HCT recipients in this study were admitted a median of 106 days during their last year of life, costing the system $558,136 in inpatient expenses per patient. CONCLUSIONSAllogeneic HCT recipients who die within a year of transplantation frequently receive a number of intensive end-of-life care interventions, as evidenced by the fact that 84% of the patients die in the hospital and 48% are admitted to the ICU at the end-of-life. Further work is needed to determine if these rates are consistent with patients' goals and whether interventions like earlier end-of-life conversations and/or palliative care consults may decrease intensity of care in this population as in non-HCT oncology patients. DisclosuresNo relevant conflicts of interest to declare.

Coronavirus Disease 2019 Policy Restricting Family Presence May Have Delayed End-of-Life Decisions for Critically Ill Patients.

To determine if a restrictive visitor policy inadvertently lengthened the decision-making process for dying inpatients without coronavirus disease 2019. Regression discontinuity and time-to-event analysis. Two large academic hospitals in a unified health system. Adult decedents who received greater than or equal to 1 day of ICU care during their terminal admission over a 12-month period. Implementation of a visit restriction policy. We identified 940 adult decedents without coronavirus disease 2019 during the study period. For these patients, ICU length of stay was 0.8 days longer following policy implementation, although this effect was not statistically significant (95% CI, -2.3 to 3.8; p = 0.63). After excluding patients admitted before the policy but who died after implementation, we observed that ICU length of stay was 2.9 days longer post-policy (95% CI, 0.27-5.6; p = 0.03). A time-to-event analysis revealed that admission after policy implementation was associated with a significantly longer time to first do not resuscitate/do not intubate/comfort care order (adjusted hazard ratio, 2.2; 95% CI, 1.6-3.1; p < 0.0001). Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death. Further policy evaluation and programs enabling access to family-centered care and palliative care during the ongoing coronavirus disease 2019 pandemic are imperative.

Postmortem radiologic and pathologic findings in COVID-19: The Toronto experience with pre-hospitalization deaths in the community

Over a year after the initial emergence of the disease, the COVID-19 pandemic continues to strain healthcare systems worldwide. The value of feedback and connection between clinical care, public health, and death investigation systems has never been more clear. To this end, knowledge of the radiologic and histopathologic features of fatal COVID-19 is critical for those working with the living and the dead. Most of the medical descriptions of COVID-19 are either focused on clinical in vivo medical imaging or autopsies performed following an intensive course of treatment over days to weeks prior to death, rather than deaths in the community prior to hospitalization. Here we report the postmortem computed tomography (PMCT) and lung histopathology in five fatal cases of COVID-19 that were subject to medicolegal death investigation. All individuals died in the community without medical treatment, or after a brief terminal admission to hospital. In these cases, the main PMCT findings included: diffuse lung changes including ground glass-type opacifications, a “crazy paving” appearance, variable areas of more dense consolidation, and relatively few areas of spared/less involved lung parenchyma. The unifying histopathology was diffuse alveolar damage in various stages of cellular evolution. In all cases, the pattern of PMCT and the lung histopathology corroborated the diagnosis of COVID-19. We propose the routine use of PMCT as a potential screening tool for the identification of COVID-19 related fatalities in the medicolegal setting where a paucity of historical information may not otherwise permit the identification of this disease prior to autopsy.

Healthcare utilisation in the last year of life in internal medicine, young-old versus old-old

BackgroundWith increasing cost of healthcare in our aging society, a consistent pain point is that of end-of-life care. It is particularly difficult to prognosticate in non-cancer patients, leading to more healthcare utilisation without improving quality of life. Additionally, older adults do not age homogenously. Hence, we seek to characterise healthcare utilisation in young-old and old-old at the end-of-life.MethodsWe conducted a single-site retrospective review of decedents under department of Advanced Internal Medicine (AIM) over a year. Young-old is defined as 65–79 years; old-old as 80 years and above. Data collected was demographic characteristics; clinical data including Charlson Comorbidity Index (CCI), FRAIL-NH and advance care planning (ACP); healthcare utilisation including days spent in hospital, hospital admissions, length of stay of terminal admission and clinic visits; and quality of end-of-life care including investigations and symptomatic control. Documentation was individually reviewed for quality of communication.ResultsOne hundred eighty-nine older adult decedents. Old-old decedents were mostly females (63% vs. 42%, p = 0.004), higher CCI scores (7.7 vs 6.6, p = 0.007), similarly frail with lower polypharmacy (62.9% vs 71.9%, p = 0.01). ACP uptake was low in both, old-old 15.9% vs. young-old 17.5%. Poor prognosis was conveyed to family, though conversation did not result in moderating extent of care.Old-old had less healthcare utilisation. Adjusting for sex, multimorbidity and frailty, old-old decedents had 7.3 ± 3.5 less hospital days in their final year. Further adjusting for cognition and residence, old-old had 0.5 ± 0.3 less hospital admissions. When accounted for home care services, old-old spent 2.7 ± 0.8 less hospital days in their last admission.ConclusionThere was high healthcare utilisation in older adults, but especially young-old. Enhanced education and goal-setting are needed in the acute care setting. ACP needs to be reinforced in acute care with further research to evaluate if it reduces unnecessary utilisation at end-of-life.

Patients With Fibrotic Interstitial Lung Disease Receive Supportive and Palliative Care Just Prior to Death.

Fibrotic interstitial lung diseases (f-ILDs) are often progressive and incurable. As patients experience significant symptoms and have a poor prognosis, early palliative care referral is recommended. To examine the care delivered to patients with f-ILD during the terminal hospital admission and the past 2 years of life. A retrospective audit was performed for consecutive patients who died from f-ILD at 2 Australian teaching hospitals between January 1, 2012, and December 31, 2016. Of 67 patients, 44 (66%) had idiopathic pulmonary fibrosis. Median age was 78 years. Median respiratory function: forced expiratory volume in 1 second 69.0% predicted (interquartile range [IQR]: 58.0%-77.0%), forced vital capacity 64.0% predicted (IQR = 46.8%-74.3%), and diffusing capacity of carbon monoxide 36.0% predicted (IQR = 31.0%-44.0%). In the 2 years prior to the terminal admission, 38 (57%) patients reported severe breathlessness and 17 (25%) used opioids for symptom relief. Twenty-four (36%) patients received specialist palliative care (SPC) and 11 (16%) completed advance care planning. During the terminal admission, 10 (15%) patients were admitted directly under SPC. A further 33 (49%) patients were referred to SPC, on average 1 day prior to death. Sixty-three (94%) patients received opioids and 49 (73%) received benzodiazepines for symptom management. Median starting and final opioid doses were 10 and 23 mg oral morphine equivalent/24 hours, respectively. Opioids were commenced on average 2 (IQR 1-3) days prior to death. Although most patients were identified as actively dying in the final admission, referral to SPC and use of palliative medications occurred late. Additionally, few patients accessed symptom palliation earlier in their illness.