Timing Of Palliative Care Consultation Research Articles

Timing of Palliative Care Consultation and End-of-Life Care Intensity in Pediatric Patients With Advanced Heart Disease: Single-Center, Retrospective Cohort Study, 2014-2022.

Pediatric patients with advanced heart disease (AHD) often receive high intensity medical care at the end of life (EOL). In this study, we aimed to determine whether receipt and timing of pediatric palliative care (PPC) consultation was associated with EOL care intensity of pediatric patients with AHD. Retrospective cohort study. Single-center, 16-bed cardiac ICU (CICU) in a children's hospital in the Mountain West. Pediatric patients (0-21 yr) with AHD treated in the CICU and subsequently died from January 2014 to December 2022. None. We compared demographics, EOL characteristics and care, including medical interventions and mortality characteristics for patients by receipt and timing of PPC (i.e., ≥ 30 d from [early] or < 30 d of death [late]) using chi-square and Wilcoxon rank-sum tests. Of 218 patients, 78 (36%) did not receive PPC, 76 received early PPC (35%), and 64 received late PPC (29%). Compared with patients who did not receive PPC, patients receiving PPC had lower EOL care intensity (77% vs. 96%; p = 0.004) and fewer invasive interventions within 14 days of death (74% vs. 92%; p = 0.004). Receipt of PPC, vs. not, was associated with lower rate of death during cardiopulmonary resuscitation (12% vs. 32%; p = 0.004) and more use of comfort care (23% vs. 3%; p = 0.004). Among patients receiving PPC, early PPC was associated with fewer invasive interventions within 14 days of death (65% vs. 85%; p = 0.033). Care intensity was high for patients with early and late PPC. Early PPC was associated with fewer invasive interventions within 14 days of death, yet the care intensity at EOL remained high. With early PPC, families likely receive timely psychosocial and advance care planning support without significantly altering goals of care.

Gender Differences Regarding Palliative Care Consultation Among Persons Hospitalized With Heart Failure

ContextPalliative care is increasingly recognized as an important aspect of heart failure (HF) management, but data on gender differences regarding palliative care needs are scarce. ObjectiveWe retrospectively studied patients hospitalized with a primary diagnosis of HF who received an initial palliative care consultation in the Mount Sinai Health System to examine gender differences. MethodsFrom electronic health records, we extracted patient information, diagnostic codes, and the palliative care consult assessment which included the Karnofsky performance status (KPS) and the Edmonton symptom assessment scale (ESAS). The population was stratified according to self-identified gender. Unadjusted and adjusted generalized linear models were fitted to study the association of gender with KPS and ESAS scores. ResultsAmong 667 patients with HF who received a palliative care consultation, 327 (49.0%) were women. Women with HF were older than men and less likely to be married. As compared to men, women had worse functional status, were less likely to have capacity to designate a surrogate medical decision-maker, had a higher symptom burden and were more likely to experience severe symptoms at the time of initial palliative care consultation. Differences in functional status and symptom burden were particularly pronounced in young women and women identifying as Black or Hispanic. The association of gender with functional status and symptom burden remained statistically significant after adjusting for possible confounders. ConclusionAs compared to men, women with HF were more severely impaired at the time of palliative care consult, and dedicated efforts to better address their needs are warranted.

Effect of timing of palliative care consultation on survival and end-of-life care outcomes in mNSCLC.

247 Background: Early specialist palliative care (PC) involvement in metastatic non-small cell lung cancer (mNSCLC) is associated with improved quality of life, less aggressive end of life (EoL) care, and longer survival. However, PC utilization remains low, and treatment paradigms have evolved. We examined how the timing and extent of PC involvement impacted outcomes in patients with mNSCLC in the era of targeted- and immune-therapy. Methods: This retrospective review analyzed patients with mNSCLC who initiated first-line treatment with chemotherapy, immunotherapy, or combined chemoimmunotherapy at Duke University between March 2015 and July 2019 and had at least one PC visit. Data were abstracted through November 2022. Patient outcomes data, including the NCCN Distress Thermometer (DT), survival, and EoL care, were analyzed using descriptive statistics. Aggressive EoL care was defined as any cancer-directed therapy, &gt;1 emergency department visit, &gt;1 hospital admission, or &gt;14 days spent in the hospital in the last 30 days of life; or hospice entry within the last 3 days of life or in-hospital death. To examine associations between PC utilization and timing of PC referral with actionable distress we fit generalized estimating equations. Results: The 60 patients were stratified by time to first PC encounter and total number of PC visits. Average age was 63.6 years, 53% were female, and 60% Caucasian. 32% were seen within 2 months of diagnosis (early), 37% between 2-6 months (moderate), and 32% were seen by PC after 6 months (late). 27% of patients saw outpatient PC only once, 43% between 2-4 times, and 30% saw PC 5 or greater times. There was no evidence of an association between PC utilization and actionable distress (NCCN DT score of 4 or greater) nor with timing of PC referral and actionable distress. Median survival was 15.3 months in the early PC group, 6.2 months in the moderate group, and 17.0 months in the late group, with a median survival of 12.5 months. Patients who received early PC spent more time on hospice (45.5 days) compared to those with moderate (29.6 days) and late (22.5 days) PC. Receipt of aggressive EoL care was high overall; 32% of patients with early PC visits received aggressive EoL care compared to 50% in moderate and 63% in late PC groups. Of the 51 decedents, only 30 (59%) enrolled in hospice. 11% of patients in the early PC group died in the hospital, compared to 14% in the moderate and 21% in the late groups. Conclusions: This real-world study reveals that referrals to PC still occur late in the disease course of mNSCLC, despite proven benefits of early integration. Early PC resulted in longer time on hospice, lower frequency of aggressive EoL care, and lower rates of in-hospital death, with no evidence of decreased survival. These findings suggest that early specialist PC improves outcomes in the era of novel mNSCLC therapies, but that PC remains underutilized, and many unmet needs persist in this population.

S1380 Examination of Timing of Palliative Care Consultation in Patients With Grade 3 Acute on Chronic Liver Failure at a Large Academic Transplant Center

S1380 Examination of Timing of Palliative Care Consultation in Patients With Grade 3 Acute on Chronic Liver Failure at a Large Academic Transplant Center

Regional adaptation of the education in palliative and end-of-life Care Pediatrics (EPEC-Pediatrics) curriculum in Eurasia.

Pediatric palliative care (PPC) is a priority to improve pediatric hematology oncology (PHO) care in Eurasia. However, there are limited regional opportunities for PPC education. We describe the adaptation and implementation of a bilingual end-user Education in Palliative and End-of-Life Care (EPEC)-Pediatrics course for PHO clinicians in Eurasia. Due to COVID-19, this course was delivered virtually, consisting of prerecorded, asynchronous lectures, and a bilingual workshop with interactive lectures and small group sessions. A pre-postcourse design was used to evaluate the knowledge acquisition of the participants including their knowledge alignment with World Health Organization (WHO) guidance, ideal timing of palliative care, and comfort in providing palliative care to their patients. Questions were mostly quantitative with multiple choice or Likert scale options, supplemented by free-text responses. A total of 44 (76%) participants from 14 countries completed all components of the course including pre- and postcourse assessments. Participant alignment with WHO guidance improved from 75% in the pre- to 90% in the postcourse assessments (p < 0.001). After participation, 93% felt more confident controlling the suffering of children at the end of life, 91% felt more confident in prescribing opioids and managing pain, and 98% better understood how to hold difficult conversations with patients and families. Most participants (98%) stated that they will change their clinical practice based on the skills and knowledge gained in this course. We present a successful regional adaptation of the EPEC-Pediatrics curriculum, including novel delivery of course content via a virtual bilingual format. This course resulted in significant improvement in participant attitudes and knowledge of PPC along with an understanding of the ideal timing of palliative care consultation and comfort in providing PPC to children with cancer. We plan to incorporate participant feedback to improve the course and repeat it annually to improve access to high-quality palliative care education for PHO clinicians in Eurasia.

Utilization of Palliative Care for Patients with Acute Kidney Injury and COVID-19 (S541)

Outcomes1. Understand the historical use of palliative care for patients with acute kidney injury (AKI)2. Describe the use of palliative care for patients with AKI and COVID-19 during the surge at our institution3. Describe the associations of palliative care with subsequent health care utilization such as hospice use, ICU time, and mechanical ventilationOriginal Research BackgroundAcute kidney injury (AKI) is a common morbidity seen in patients with COVID-19 and is associated with high mortality. Palliative care is valuable for these patients yet is historically underused in AKI.Research ObjectivesTo describe the use of palliative care and subsequent health care utilization by COVID-19 patients with AKI.MethodsA retrospective analysis of NYU's electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. AKI was defined by the AKI Network creatinine criteria. Regression models examined characteristics associated with a receiving palliative care and discharge to hospice versus death in the hospital.ResultsPatientswith COVID-19 and AKI were more likely than those without AKI to receive palliative care (42% vs 7%, p < 0.001); however, consults came significantly later (10 days from admission vs 5 days, p < 0.001). 66% of patients initiated on renal replacement therapy (RRT) received palliative care versus 37% (p < 0.001) of those with AKI not on RRT, also later in timing (12 days from admission vs 9 days, p = 0.002). Patients with AKI had a significantly longer stay, more ICU admissions, use of mechanical ventilation, discharges to hospice (6% vs 3%), and changes in code status (34% vs 7%, p < 0.001) than those without AKI. Among those who received palliative care, AKI both without RRT (adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.27-0.95) and with RRT (aOR 0.18, 95% CI 0.04-0.67) was associated with a lower likelihood of discharge to hospice versus hospital death compared to those without AKI.ConclusionPalliative care was used more for patients with AKI and COVID-19 than historically reported, yet this consultation came later in the hospital course and did not avoid invasive interventions despite high mortality.Implications for Research, Policy, or PracticeThese data can lead to further exploration of earlier timing of palliative care consultation in AKI.

When does early palliative care influence aggressive care at the end of life?

Early palliative care improves patient quality of life and influences cancer care. The time frame of early has not been established. Eight quality measures reflect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018, through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL). Patients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30days, 30-90days, and greater than 90days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with confidence intervals (CI) was reported as a measure of effect size. A p value ≤ 0.05 was considered significant. 1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). Seventy-one percent had a palliative care consult, 26% completed AD, and 888 (51.4%) had at least one indicator of ACEOL. The most common indicator of ACEOL was new chemotherapy within 30days of death, in 571 of 888 (64%) of patients experiencing ACEOL. ADs completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64-0.99). Palliative care initiated at 30days was associated with a greater risk of ACEOL (OR 5.32, 95% CI 3.94-7.18) and initiated between 30 and 90days (OR 1.39, 95% CI 1.07-1.80) compared to no palliative care but was associated with reduced chemotherapy as an indicator of ACEOL when > 90days (OR 0.46, 95% CI 0.38-0.57) before death. Completed ADs were associated with reduced chemotherapy in the last 30days of life and reduced ICU admissions. This may reflect goals of care and end-of-life discussions and transition of care to comfort measures. Palliative care paradoxically when initiated within 90days before death was associated with greater ACEOL compared to no palliative care. This may be due to consultation late in the course of illness with a focus on crisis management in patients frequently utilizing the health care system. There is an associated reduction in the use of chemotherapy in the last 30days of life if palliative care is consulted 90days prior to death. An initial palliative care consult greater than 90days before death and ADs completed at any time during the disease trajectory was associated only with reduced chemotherapy in the last 30days of life compared with no palliative care among the 7 ACEOL indicators. ADs were associated with reduced ICU admissions. Most palliative care consults occurred within 90days of death and a palliative care consult within 90days of death is not an optimal utilization of services.

Quality of End-of-Life Care for People with Advanced Non-Small Cell Lung Cancer in Ontario: A Population-Based Study.

Ensuring high quality end of life (EOL) care is necessary for people with advanced non-small-cell lung cancer (NSCLC), given its high incidence, mortality and symptom burden. Aggressive EOL care can adversely affect the quality of life of NSCLC patients without providing meaningful oncologic benefit. Objectives: (1) To describe EOL health services quality indicators and timing of palliative care consultation provided to patients dying of NSCLC. (2) To examine associations between aggressive and supportive care and patient, disease and treatment characteristics. Methods: This retrospective population-based cohort study describes those who died of NSCLC in Ontario, Canada from 2009–2017. Socio-demographic, patient, disease and treatment characteristics as well as EOL health service quality and use of palliative care consultation were investigated. Multivariable logistic regression models examined factors associated with receiving aggressive or supportive care. Results: Aggressive care quality indicators were present in 50.3% and supportive care indicators in 60.3% of the cohort (N = 37,203). Aggressive care indicators decreased between 2009 and 2017 (57.4% to 45.3%) and increased for supportive care (54.2% to 67.5%). Benchmarks were not met by 2017 in 3 of 4 cases. Male sex and greater comorbidity were associated with more aggressive EOL care and less supportive care. Older age was negatively associated and rurality positively associated with aggressive care. No palliative care consultation occurred in 56.0%. Conclusions: While improvements in the use of supportive rather than aggressive care were noted, established Canadian benchmarks were not met. Moreover, there is variation in EOL quality between groups and use of earlier palliative care must improve.

The Magnitude and Effects of Early Integration of Palliative Care Into Oncology Service Among Adult Advanced Cancer Patients at a Tertiary Care Hospital.

BackgroundPalliative care (PC) has a positive effect on symptom burden, quality of life, psychosocial communication, prognostic understanding, mood, and quality of care at the end of life of patients with advanced cancer.ObjectivesTo investigate the timing of the first palliative consultation and referral of advanced cancer patients to the palliative care service and their determinants at King Faisal Specialist Hospital and Research Center (KFSHRC), Jeddah, Saudi Arabia.Subjects and methodsA retrospective cohort study was conducted at KFSHRC. It included advanced cancer patients who died between January 1, 2019 and Jun 30, 2020. The dependent variable of primary interest is the timing of PC consultation and the timing of PC referral. The independent variables included age, sex, marital status, nationality, date of death, types of cancer, Eastern Cooperative Oncology Group (ECOG), palliative performance status (PPS), palliative prognostic index (PPI), code status (do not resuscitate [DNR]), the severity of symptoms (assessed by the Edmonton Symptom Assessment System - Revised [ESAS-r]), referral to home health care (HHC), referral to long-term care (LTC), referral to interdisciplinary team (IDT), length of survival after the first PC consultation, length of survival after the referral to the PC service, length of hospital stay, frequency of emergency room (ER) visits and hospital admission in the last year before death, and involvement in bereavement with advanced care planning (ACP) services.ResultsOf the 210 advanced cancer patients, 109 (51.9%) were male, and their ages ranged between 18 and 90 years. More than half of patients (56.7%) had a history of PC consultation. Among them, PC consultation was described as late in 60.5% of patients. Concerning the timing of palliative care referral among advanced cancer patients, it was too late and much too late among 25.7% and 58.1% of them, respectively. Patients who visited ER more frequently (≥3 times) (p=0.014) and those who referred to HHC (p=0.005) were more likely to consult PC early compared to their counterparts. Length of survival was significantly higher among patients who reported early PC consultation compared to those without PC consultation and those with late PC consultation, p<0.001. Referral to PC for both transfer of care and symptom management was associated with earlier PC consultation, p=0.021. Patients who were admitted to the hospital three times or more were less likely to be much too late referred to PC services, p=0.046. Also, patients who were not referred to long-term care or home health care were more likely to be referred to PC services much too late, p<0.001. Among 28.8% of patients whose PPS ranged between 30% and 50% compared to 14.9% of those whose PPS ranged between 10% and 20% expressed too late referral time to PC, p=0.040.ConclusionIn a considerable proportion of terminal cancer patients, palliative care was consulted late, and the timing of palliative care referral was too late/much too late among most of those consulted palliative care. Length of survival was higher among patients who reported early PC consultation and who with ideal referral time to PC services than others. Therefore, future considerations to facilitate early integration of palliative care in cancer patients are highly recommended through mainly improving staff education in communication skills and palliative care approach.

Palliative Care Consultation and Effect on Length of Stay in a Tertiary-Level Neurological Intensive Care Unit.

Background: Patients admitted to an acute care setting with a devastating brain injury are at high risk for morbidity and mortality. These patients and their families can benefit from the psychosocial and decision-making support of a palliative care consultation.Objective: We aim to investigate the characteristics and impact of palliative care consultation for patients under the management of neurosurgical and critical care services with a devastating brain injury in a neurological intensive care unit (ICU) at a large tertiary-care hospital.Design: Data were collected by retrospective review of the electronic medical record and metrics collected by the palliative care service. Data were analyzed using descriptive statistics. Linear regression analysis was performed to assess effect of timing of palliative care consultation.Results: Fifty-five patients admitted to the neurological ICU under the management of the neurosurgical service received a palliative care consultation for the following: hemorrhagic stroke (49%), metastatic cancer (22%), and traumatic brain injury (18%). Of these, 73% had at least one neurosurgical intervention. Palliative care was most frequently consulted for assistance in defining a patient's goals of care (88%). When compared with late consultation, early palliative care consultation was significantly associated with shorter mean length of stay (LOS) and positively correlated in linear regression analysis without an effect on mortality.Conclusions: When compared with a late consultation, early palliative care consultation corresponded to shorter LOS without increasing mortality. One reason for this effect may be that palliative care can help to clarify and document goals of care earlier and more concretely.

Frequency, Timing, and Predictors of Palliative Care Consultation in Patients with Advanced Cancer at a Tertiary Cancer Center: Secondary Analysis of Routinely Collected Health Data.

Early integration of palliative care (PC) with oncological care is associated with improved outcomes in patients with advanced cancer. Limited information exists on the frequency, timing, and predictors of PC consultation in patients receiving oncological care. The Cross Cancer Institute (CCI) is the sole tertiary cancer center serving the northern half of the Canadian province of Alberta, located in the city of Edmonton. The objectives of this study were to estimate the proportion of patients with advanced cancer at the CCI who received consultation by the CCI PC program and the comprehensive integrated PC program in Edmonton, and to determine the timing and predictors of consultation. In this secondary analysis of routinely collected health data, adult patients who died between April 2013 and March 2014, and had advanced disease while under the care of a CCI oncologist, were eligible. Data from the Alberta Cancer Registry, electronic medical records, and Edmonton PC program database were linked. Of 2,253 eligible patients, 810 (36%) received CCI PC consultation. Median time between consultation and death was 2 months (range, 1.1-5.4). In multivariable logistic regression analysis, age, residence, income, cancer type, and interval from advanced cancer diagnosis to death influenced odds of receiving consultation. Among 1,439 patients residing in Edmonton, 1,121 (78%) were referred to the Edmonton PC program. A minority of patients with advanced cancer received PC consultation at the tertiary cancer center, occurring late in the disease trajectory. Frequency and timing of PC consultation varied significantly, according to multiple factors. Clinical and demographic factors are associated with variations in frequency and timing of palliative care consultation at a cancer center and may, in some cases, reflect barriers to access that warrant attention.

Access to Pediatric Palliative Care in the Neonatal Intensive Care Unit by Minorities and Rural-Dwellers in the Deep South: Patterns of Care from 2009-2017 (S816)

1.Describe patterns of pediatric palliative care and care disparities in neonatal intensive care unit (NICU) patients and families hospitalized in the Deep South (Alabama, Louisiana, and Mississippi).2.Describe implications for practice related to current trends of pediatric palliative care use in the NICU and implications for future research. Pediatric mortality is the highest in the first year of life. In 2013, 23,446 infants died in the U.S. Access to timely pediatric palliative care (PPC) services are limited for seriously ill infants and their families in the U. S. Deep South. Patterns of PPC in the neonatal intensive care unit (NICU) and the extent of PPC disparities in the Deep South are unknown. Examine racial and geographical differences in pediatric palliative care (PPC) consultation for seriously ill infants in the neonatal intensive care unit. This was a retrospective medical record review of infant decedents who received PPC while hospitalized in a level III NICU at an academic children’s hospital in Alabama from 2009-2017. Demographic characteristics, timing of palliative care consultation, hospice enrollment, final resuscitation status, circumstances at time of death, and interventions received in the last 48 hours of life. Data were analyzed in SPSS using descriptive statistics and t-tests. The percentage of infants receiving PPC in the NICU increased over time from 7% in 2009 to 38% in 2017. Infant decedents (N=140) who received PPC in the NICU were mostly Caucasian (58%) and African American (39%), receiving Medicaid (84%), and had genetic (53%) and prematurity (34%) diagnoses. There were no statistically significant differences between racial or urban versus rural groups in the timing of PPC consultation during the NICU admission. Infants who lived over 1 hour away received PPC significantly later than infants living less than 1 hour away from the NICU (p= 0.03). There were no racial or rurality differences in PPC timing during hospitalization; however, traveling over an hour to the hospital was associated with a delay in receiving PPC.

Association of emergency department admission and early inpatient palliative care consultation with hospital mortality in a comprehensive cancer center

Consultation to palliative care (PC) services in hospitalized patients is frequently late after admission to a hospital. The purpose of this study is to examine the association of in-hospital mortality and timing of palliative care consultation in cancer patients admitted through the emergency department (ED) of MD Anderson Cancer Center. Institutional databases were queried for unique medical admissions over a period of 1year. Primary cancer type, ED versus direct admission, length of stay (LOS), presenting symptoms, and in-hospital mortality were reviewed; patient data were analyzed, and risk factors for in-hospital mortality were identified. The association of early palliative care consultation (within 3days of admission) with these outcomes was studied. Descriptive statistics and multivariate logistic regression model were used. Equal numbers of patients were admitted directly versus through the ED (7598 and 7538 respectively). However, of all patients who died in the hospital, 990 (88%) were admitted through the ED, compared with 137 admitted directly (P < 0.001). Patients who died in the hospital had longer median LOS compared with patients who were discharged alive (11 vs. 4days, respectively, P < 0.001). Early palliative care consultation was associated with decreased mortality, compared with late consultation (P < 0.001). Chief complaints of respiratory problems, neurologic issues, or fatigue/weakness were significantly associated with in-hospital mortality. We found an association between ED admission and hospital mortality. Decedent cancer patients had a prolonged LOS, and early palliative care consultation for terminally ill symptomatic patients may prevent in-hospital mortality and improve quality of cancer care.

Impact of palliative care (PC) consultation on quality of end-of-life (EOL) care in advanced cancer patients receiving care at a tertiary cancer center (TCC).

129 Background: Early integration of PC with oncological care has been shown to improve outcomes in patients with advanced cancer, including quality of life and mood. It has also been suggested to have a positive impact on quality of EOL care. The purpose of our study was to examine how occurrence and timing of PC consultation are associated with quality of EOL care in advanced cancer patients receiving care at a Canadian TCC. Methods: In this retrospective study, patients who died between April 1, 2013 and March 31, 2014, had advanced cancer while receiving care at our TCC, and lived in the catchment area of our urban comprehensive integrated PC program were eligible. Date of death, demographics, and cancer type were obtained from the cancer registry. Date of diagnosis of advanced cancer was determined from electronic medical records. Occurrence and date of PC consultation were identified from the PC database. Data on quality of EOL care indicators were retrieved from the cancer registry, including, in the last 30 days of life: emergency room visits, hospital admission, hospitalization &gt; 14 days, ICU admission, death in hospital, and chemotherapy use. Results: Of 1414 eligible patients, 1101 (77.9%) received PC consultation in hospital, outpatient clinic, or community. Patients who received PC consultation were younger than those who did not receive PC consultation (age 68.8 vs. 71.0, p = 0.01), and differed in the frequency of cancer types (p &lt; 0.001), but not sex, marital status, or income. 679 patients (48.0%) had at least 1 indicator of quality of EOL care. Patients who did and did not receive PC consultation did not differ in the frequency of any indicators of quality of EOL care. There were also no differences in frequency of quality of EOL care indicators between patients who received their first PC consultation &gt; 3 months vs. ≤3 months or &gt; 6 months vs. ≤6 months before death. Conclusions: Among advanced cancer patients receiving care at our TCC, occurrence and timing of PC consultation did not affect quality of EOL care. Methodological and healthcare system differences may explain the discrepancy between our results and those of other investigators. Further research is needed.

Chemotherapy in the ICU: Association between palliative care consultation and care goal documentation.

e21516 Background: Patients receiving chemotherapy in the intensive care unit (ICU) are at high risk of morbidity and mortality. A growing consensus supports proactively addressing goals of care (GOC) - prognosis, goals, fears, and treatment preferences - rather than waiting until treatment options are exhausted. Palliative care consultations frequently address GOC but most often occur late in cancer care. We hypothesized that palliative care consultation is associated with an increased likelihood of GOC documentation. Methods: We reviewed electronic medical records of all patients who received chemotherapy for a cancer diagnosis in OHSU ICUs from 2010-2015, collecting patient demographics, cancer diagnoses and comorbidities, timing of palliative care consultation, chemotherapy administration, GOC documentation, and survival at 30 and 180 days following ICU discharge. Survival and diagnosis were also checked against the OHSU Tumor Registry. Results: 214 patients met our inclusion criteria. Demographics reflect the Oregon population, but with a male predominance (64.5% male, N = 138). A majority of ICU patients receiving chemotherapy had a hematologic malignancy (80%, N = 172), and acute respiratory failure as the reason for ICU admission (42%, N = 90). The majority (84%, N = 179) survived their ICU stay and 67% (N = 143) survived 30 days post-ICU discharge, whereas 50% (N = 108) died by 180 days post-ICU discharge. Documentation of GOC discussions was found for 95 patients (44%) and was more likely in patients receiving palliative care consult (71/72 = 99%) compared to those who did not (24/142 = 17%), p &lt; 0.0001, Fisher’s exact test. 63% of conversations occurred after chemotherapy had already been given (60.6% when palliative care was consulted, 70.8% when not, p = 0.4656). Conclusions: Chemotherapy in the ICU was associated with a 16% chance of dying in the ICU and a 50% 6 month mortality overall. Despite this, only 44% had documented GOC conversations and 63% of the conversations occurred after chemotherapy was initiated. Palliative care consultation was not associated with earlier GOC conversations. We recommend routine GOC conversations be initiated by oncologists prior to giving chemotherapy in the ICU setting.

P159 Frequency and Timing of Palliative Care Consultation in Patients with Advanced Cancer Receiving Care at a Tertiary Cancer Centre

P159 Frequency and Timing of Palliative Care Consultation in Patients with Advanced Cancer Receiving Care at a Tertiary Cancer Centre

Unmet Needs of African Americans and Whites at the Time of Palliative Care Consultation.

Differences among patient populations that present to consultative palliative care are not known. Such an appreciation would inform health-care delivery tailored to unique populations. We aimed to compare characteristics and palliative care needs of African Americans (AAs) and whites during initial palliative care consultation. We analyzed patient-reported, clinician-entered clinical encounter data from a large, multisite community-based, nonhospice palliative care collaborative. We included first specialty palliative care consultations from January 1, 2014, to July 2, 2015, across 15 sites within the Global Palliative Care Quality Alliance registry. Demographics, disease, performance status, advance care planning, and symptom prevalence/severity were compared. Of 775 patients, 12.9% (N = 100) were AA. African Americans were younger (63 vs 75.4 years, P < .0001). A larger proportion of AAs had a diagnosis of cancer (45.0% vs 36.3%, P = .09) and in the hospital (71% vs 61.8%, P = .07). African Americans were more likely to have a Palliative Performance Score of 0 to 30 (35.6% vs 23.7%, P = .049). Around 50% in both racial groups were full code; slightly more than 40% had an advance directive. Nearly two-thirds in both racial groups reported 3 or more symptoms of any severity; one-third reported 3 or more moderate or severe symptoms. A larger proportion of Africans than whites reported pain of any severity (66.0% vs 56.1%, P = .06). All patients present to palliative care consultations with significant symptom and advance care planning needs. Further research is needed to identify how to deliver palliative care: earlier, in noncancer conditions, and improve pain management in AA populations.

Care Quality and Cost Implications of the Timing of Palliative Care Consultation Among Patients with Advanced Cancer Treated at the UCSF Helen Diller Comprehensive Cancer Center (SA516-A)

Review proposed procedures for pacemaker deactivation as developed by a tertiary university-based hospital. In the last several years, much has been written about the practical and ethical considerations regarding the deactivation of cardiac implantable electronic devices (CIEDs) in patients at the end of life. While deactivation of certain devices, such as implantable cardiac defibrillators, has become relatively common, other devices carry significantly more controversy and potential for conflict between patients and providers, as well as among medical professionals. Indeed, recent surveys have revealed that the majority of physicians remain uncomfortable discussing deactivate of CIEDs in general and pacemakers in particular. We will begin this concurrent session with a case report of a family’s distress when their request for pacemaker deactivation in a patient with terminal cancer was met with accusations of euthanasia, and then review the literature regarding consensus and opinions regarding pacemaker deactivation. We will detail the experiences of one university-based hospital’s attempt to develop a policy for pacemaker deactivation with an emphasis on practical lessons learned. We will review the results of a national survey of hospital-based ethics committees regarding their experience with pacemaker deactivation. Finally, we will end with a proposed procedure to manage the potential symptoms associated with pacemaker deactivation in a patient at the end of life.

Association between tobacco use and symptom expression, alcoholism, and illicit drug use in patients with advanced cancer.

154 Background: Our aim was to determine the association between smoking status and symptom expression, opioid use, alcoholism, and illicit drug use in advanced cancer patients. Methods: We retrospectively reviewed 560 consecutive charts from the outpatient Supportive Care Center and identified 300 advanced cancer patients who completed a comprehensive smoking questionnaire. Data on the Edmonton Symptom Assessment Scale (ESAS), morphine equivalent daily dose (MEDD), CAGE (Cut Down, Annoyed, Guilty, Eye Opener) questionnaire for alcoholism screening, and history of illicit drug use were collected. Results: Among 300 advanced cancer patients, 119 (40%) were never-smokers, 148 (49%) were former smokers, and 33 (11%) were current smokers. Compared with never-smokers, current smokers were more likely to be men (58% vs. 29%, P=0.004), report a higher pain expression (median 7.0 vs. 5.0 by the ESAS, P=0.007), be CAGE positive (≥2 yes response) (42% vs. 3%, P&lt;0.001), and have a history of illicit drug use (33% vs. 3%, P&lt;0.001). Compared with never-smokers, former smokers were more likely to be men (60% vs. 29%, P&lt;0.001), have head and neck cancer or lung cancer (30% vs. 13%, P=0.001), be CAGE positive (21% vs. 3%, P&lt;0.001), and have a history of illicit drug use (16% vs. 3%, P&lt;0.001). Current smokers reported a higher pain expression than former smokers (median 7.0 vs. 6.0 by the ESAS, P=0.01), had higher CAGE positivity (42% vs. 21%, P=0.01) and more frequent illicit drug use (33% vs. 16%, P=0.03). The MEDD and the timing of palliative care referral were not significantly different between current or former smokers compared with never-smokers. However, a higher proportion of current smokers were receiving opioids with MEDD ≥30mg at the time of palliative care consultation compared with never-smokers (70% vs. 52%, P=0.08). Conclusions: Our study suggests that current tobacco use is associated with a higher pain expression. In addition, any history of tobacco use is associated with a history of illicit drug use and alcoholism. Advanced cancer patients who smoked cigarettes may be at an increased risk for chemical coping or stronger opioid utilization and further studies are needed.

Care, quality, and cost implications of the timing of palliative care consultation among patients with advanced cancer.

8 Background: ASCO recommends that early palliative care (PC) be offered alongside standard cancer care for patients with metastatic cancer and/or high symptom burden. There is limited data about how the timing of PC affects the quality, intensity, and cost of care at the end of life for patients with advanced cancer. Methods: We analyzed administrative and billing data to assess patterns of healthcare utilization for a cohort of patients at an academic comprehensive cancer center who died from cancer between Jan 1, 2010 and May 31, 2012. We examined the associations of early PC (&gt;90 days prior to death) versus late PC (&lt;90 days prior to death) with QOPI, NQF, and other established quality metrics and direct cost of medical care in last 6 months of life. Results: Among 978 decedents who received treatment at the cancer center, only 298 (30%) had specialty PC referrals. Of these patients, 94 (9.6% of decedents, 31.5% of referrals) had early PC while 204 (21% of decedents, 68.5% of referrals) had late PC. Patients who received early PC had a lower rate of inpatient admissions in the last month of life (33% vs. 66%, p=0.002), lower rates of ICU stay in last month of life (5% vs. 20%, p=0.0005), fewer ED visits in last month (34% vs. 54%, p=0.0002), fewer instances of hospice length of service &lt;3 days (7% vs. 20%, p=0.0001), and a lower rate of inpatient death (15% vs. 34%, p=0.0001). Most patients (84%) who received early PC were seen as outpatients, while late PC was mostly delivered in the hospital (82.4%). Of the late PC cohort, only 52 (25.4%) were ever seen in the outpatient PC clinic, but 170 (83%) had at least one oncology office visit 91-180 days prior to death. The direct cost of inpatient medical care in the last 6 months of life for patients with early PC was reduced when compared to patients who had late PC ($19k vs. $25.7k), while the direct cost of outpatient care was higher in the early PC compared to late PC population ($13k vs. $11.5k). Conclusions: Early PC is associated with less intensive medical care and improved quality outcomes at the EOL for patients with advanced cancer. Early PC results in a significant inpatient cost savings with a modest increase in outpatient costs. Early PC is likely best delivered in the outpatient setting.