Timing Of Palliative Care Referral Research Articles

Impact of Palliative Care Referral on End-of-Life Outcomes for Patients With Hematologic Malignancy.

Compared to patients with solid malignancies, less is known about the role of palliative care in patients with hematologic malignancies, leading to underutilization of palliative care. Evaluate the timing and impact of palliative care referrals on end-of-life outcomes over a 5-year period with intent to improve the utilization of palliative care in patients with advanced hematologic malignancies. A retrospective cohort of patients from an urban, NCI-designated comprehensive cancer center, aged 18years and older with a diagnosis of an advanced hematologic malignancy were separated into groups of early, late, very late, or no specialty palliative care. Logistic regression models were constructed to examine variables associated with timing of palliative care referral. Groups were compared using the Kruskal Wallis test and Dunn's test with a Bonferroni correction method. 222 patients with advanced hematologic malignancies who died between July 1, 20218 and June 30, 2023 were included. 50 (23%), 41 (18%), and 51 (23%) patients received an early, late, and very late palliative care referral, respectively and 80 (36%) patients did not receive a palliative care referral. There was a significantly high completion of ACP documentation among the palliative care cohorts. There was no significant difference among all cohorts in end-of-life outcomes in the last 14 or 30days of life. ACP documentation improved with palliative care, however, end-of-life outcomes did not. These results are likely due to the majority of late, inpatient palliative care referrals. Future studies with targeted interventions are needed to improve these outcomes.

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, >1 emergency department visit, >1 hospital admission, or >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.

Quality of End-of-Life Care during the COVID-19 Pandemic at a Comprehensive Cancer Center.

To evaluate how the COVID-19 pandemic impacted the quality of end-of-life care for patients with advanced cancer, we compared a random sample of 250 inpatient deaths from 1 April 2019, to 31 July 2019, with 250 consecutive inpatient deaths from 1 April 2020, to 31 July 2020, at a comprehensive cancer center. Sociodemographic and clinical characteristics, the timing of palliative care referral, timing of do-not-resuscitate (DNR) orders, location of death, and pre-admission out-of-hospital DNR documentation were included. During the COVID-19 pandemic, DNR orders occurred earlier (2.9 vs. 1.7 days before death, p = 0.028), and palliative care referrals also occurred earlier (3.5 vs. 2.5 days before death, p = 0.041). During the pandemic, 36% of inpatient deaths occurred in the Intensive Care Unit (ICU) and 36% in the Palliative Care Unit, compared to 48 and 29%, respectively, before the pandemic (p = 0.001). Earlier DNR orders, earlier palliative care referrals, and fewer ICU deaths suggest an improvement in the quality of end-of-life care in response to the COVID-19 pandemic. These encouraging findings may have future implications for maintaining quality end-of-life care post-pandemic.

Immune Checkpoint Inhibitors and Palliative Care at the End of Life: An Irish Multicentre Retrospective Study.

Background and Objectives: Immune checkpoint inhibitors (ICIs) have less toxicity than standard chemotherapy and are now standard of care for many patients with advanced cancer. A manageable side effect profile and potential for durable responses may lead to aggressive care of the palliative patient. We sought to evaluate palliative care input and ICI use at the end of life at two Irish cancer centres. Methods: We identified deceased patients who received at least one dose of an ICI between first of January 2013 to 31st of December 2018. A retrospective electronic chart review was performed. Results: The electronic records of 102 patients were analysed. Fifty eight percent were male and the median age of diagnosis of advanced disease was 60 years (range 17-78). Median time from last dose of ICI to death was 57 days (range 8-574) and 20% of patients died within 30 days of last dose of ICI. Most patients, 92%, were referred to palliative care. The median time from palliative care referral to death was 64 days (range 1- 1010). In the last 30 days of life, 39% of patients attended the emergency department (ED) and 46% had at least one hospital admission. Late palliative care referrals, ≤3 months before death, were associated with hospitalisations in the last month of life (64% vs. 36%, P = .02). Timing of palliative care referral did not affect ICI prescribing at the end of life (P = 0.38). ICI use in the last 30 days of life was not associated with increased ED presentations or hospitalisations at the end of life. Patients who received ICI in the last month had a higher likelihood of in-hospital death (43% vs. 16%, P = 0.02). Conclusions: ICI within 30 days of death was associated with dying in hospital but did not lead to more hospitalisations and emergency department presentations. Early palliative care did not affect ICI use but reduced hospitalisations at the end of life.

Early referral to a palliative team improves end-of-life care among gynecological cancer patients: a retrospective, population-based study

ObjectiveTo assess end-of-life care among patients with gynecological cancer, and to describe the association between timing of palliative care referral and patterns of care.MethodsAll women with residence in Oslo, Norway,...

Optimizing timing of palliative care referral in platinum resistant ovarian cancer

Objectives: An exploration of clinical characteristics, palliative care involvement, and survival in platinum resistant ovarian cancer. Methods: This is a single institution retrospective study of all patients receiving chemotherapy for ovarian, fallopian tube, or peritoneal high-grade carcinoma since 2011. Platinum resistant patients were identified based on chemotherapy regimen or provider definition, then confirmed with clinical data. Data was extracted evaluating platinum resistant treatment, time to progression, and overall survival. Palliative care and hospice referrals were recorded. Descriptive and overall survival analyses were performed. Results: Two hundred and seventy-five platinum resistant patients were identified. Of 100 charts reviewed to date, 78 patients were deceased. The median survival from time of diagnosis of platinum resistant to death was 11.4 months (range 0.5-66 months). Of the 78 deceased patients, 25 (32%) lived less than 6 months from time of diagnosis of platinum resistance (range 0.5-5.9 months), 23 (29.5%) lived 6-12 months, and 30 (38.5%) lived more than 12 months (range 12.9-66 months). Of the 25 patients who lived less than 6 months, 17 (68%) were referred to palliative care and 6 (24%) were referred directly to hospice, 3 of which were within one month of death. Of the 23 patients who lived 6-12 months, 16 (69.5%) were referred to palliative care and 6 (26%) were referred directly to hospice, 5 of which were within one month of death. Finally, of the 30 patients who lived greater than 12 months, 23 (76.7%) were referred to palliative care and 5 (16.7%) were referred directly to hospice. In 17 (57%) of the patients living greater than 12 months after platinum resistance, referral to palliative care or hospice did not happen until the 3 months prior to death (Figure 1). Of the living patients with platinum resistant disease, median survival since diagnosis is 9.8 months. Of these patients, 11 (50%) have been referred to palliative care and 11 (50%) have no documentation of palliative care referral. Data extraction and analysis is on-going, with 175 remaining charts to review. Conclusions: Diagnosis of platinum resistance is a pivotal point in ovarian cancer treatment. Survival from time of diagnosis of platinum resistance to death is limited. National recommendations encourage routine integration of palliative care within eight weeks of diagnosis of advanced cancer in order to optimize patient and caregiver outcomes. Our work found room for improvement in the timing of palliative care referrals in platinum resistant ovarian cancer patients. Even more strikingly, we found a pattern of direct referral to hospice, without palliative care referral prior, often within a month of death. This highlights a significant missed opportunity in utilization of palliative care in the months, and potentially years, leading up to the end of life. Diagnosis of platinum resistance should serve as a stimulus for involvement of palliative care services. Download : Download high-res image (179KB) Download : Download full-size image

The association between ethnicity, socioeconomic deprivation and receipt of hospital-based palliative care for people with Covid-19: A dual centre service evaluation

Background: People from ethnic minority groups and deprived socioeconomic backgrounds have worse outcomes from COVID-19. Aim: To examine associations between ethnicity and deprivation with timing of palliative care referral for inpatients with COVID-19. Design: Service evaluation of consecutive patients with COVID-19 referred to palliative care. Sociodemographic (including age, sex, Index of Multiple Deprivation, ethnicity coded as White/non-White) and clinical variables were described. The primary outcome was timing of referral to palliative care. Associations between ethnicity and socioeconomic deprivation with the primary outcome were explored using multivariable regression. Setting/participants: Patients with COVID-19 referred to a hospital palliative care service across two London hospitals February–May 2020. Results: A total of 334 patients were included. 119 (36%) were from a non-White ethnic group; most commonly Black British (77, 23%) and Asian British (26, 8%). A longer time between admission and palliative care referral was associated with male gender (IRR 1.23, 95% CI 1.14–1.34) and lower levels of socioeconomic deprivation (IRR 1.61, 95% CI 1.36–1.90) but not ethnicity (IRR = 0.96, 95% CI 0.87–1.06). Conclusions: This large service evaluation showed no evidence that patients from ethnic minority or more deprived socioeconomic groups had longer time to palliative care referral. Ongoing data monitoring is essential for equitable service delivery.

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.

Timing of palliative care referral in patients with advanced Non-Small Cell Lung Cancer: a retrospective cohort study

Introduction: Early palliative care referral is recommended for patients with Stage IV Non-Small Cell Lung Cancer (NSCLC) irrespective of the decision to administer cancer-directed therapies. Diagnosis-to-referral and referral-to-death intervals, proposed as measures of quality of care, are rarely reported in low-and-middle income settings. Objective: to estimate the 6-month cumulative incidence of palliative care referrals and the length of referral-to-death intervals among patients with Stage IV NSCLC at a teaching hospital in Argentina. Methods: Patients with Stage IV NSCLC diagnosed between 2012 and 2017 were followed up until December 2019. We retrieved the first contact with palliative care services and date of death from centralized Electronic Health Records. Cumulative incidence of palliative care referrals was estimated by fitting a Fine & Gray competing risks model. Results: Ninety-two patients were included. Median age was 71.5 years (IQR 63–79 years), 55% were women. Median survival time was 375 days (95% CI: 204–508 days). Considering death as a competing risk, the 6-month cumulative incidence of palliative care referrals was 37% (95% CI: 27% to 47%). Among referred patients, the median referral-to-death interval was 31 days. Discussion: Further research should focus on identifying and overcoming barriers to timely palliative care referrals in this population.

Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care.

Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence. Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral. Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites. Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care. Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.

Medical oncologist perspectives on palliative care reveal physician-centered barriers to early integration.

Background:Early palliative care referral for patients with advanced cancer has demonstrable benefits but is underutilized. We sought to characterize medical oncologists’ perceptions about palliative care referral in their clinical practices.Methods:We conducted 4 focus groups with a national sample of medical oncologists to elicit perspectives about the optimal timing of and barriers to palliative care referral for patients with cancer. We used qualitative content analysis to uncover themes related to early integration of palliative care into standard oncologic practice.Results:Study participants readily acknowledged the evidence supporting early palliative care referral. However, medical oncologists identified patient-centered and physician-centered barriers to widespread adoption of early palliative care. Patient-centered barriers included patients’ and families’ perceptions or misperceptions of the role of palliative care. Additionally, physicians themselves described acting as a barrier to palliative care referral because they were concerned that palliative care physicians may interfere with the plan of care, or offer options that were not endorsed by the medical oncologist. Medical oncologists depicted themselves having authority over the timing of palliative care referral, and as granting limited autonomy to other clinical team members in counseling patients about advanced care planning.Conclusions:Medical oncologists are hesitant to adopt the practice of early palliative care referral because they are concerned that other physicians may disrupt a patient’s treatment plan. Physician-centered barriers may delay integration of palliative care, and future efforts to promote a collaborative approach to advanced care planning may improve patient-centered outcomes through access to early palliative care.

Referral Characteristics of Palliative Care Service in Patients With Advanced Non-Small Cell Lung Cancer in a Tertiary Cancer Center.

The American Society of Clinical Oncology recently recommends patients with metastatic non-small cell lung cancer (NSCLC) should be offered palliative care services earlier. We sought to investigate the timing of palliative care referral of Chinese patients with NSCLC in our center. Retrospective medical data including demographic characteristics and referral information were collected for analysis. Overall survival (OS) was calculated as the time since cancer diagnosis till patient's death. The time interval from palliative care (PC) referral to a patient's death (PC-D) was calculated. The PC-D/OS ratio was calculated to illustrate the comparison of the duration of PC in the overall length of disease. The mean age of 155 patients with advanced NSCLC was 62.83 years. Before referral to PC, 128 patients received anticancer treatment including surgeon (46.5%). Sixty-three (40.6%) patients died in palliative care unit. The median OS of 144 patients with end cutoff was 19 months (mean = 31.49, 95% confidence interval [CI] = 25.86-37.12). The median PC-D was 41 days (mean = 73.84, 95% CI = 60.37-87.40). The mean interval of PC-D/OS of 144 patients with definitely death time was 0.22 (SD: 0.27, 95% CI: 0.17-0.26). The median interval was 0.089. More than half of patients (n = 75, 51.8%) underwent PC less than 1% time (PC-D/OS < 0.1) of their whole disease course. Patients who were indigenous to Shanghai (P = .013) and who had brain metastasis (P = .072) had the potential longer PC-D/OS ratio. A high proportion of patients reported loss of appetite (92.8%) and fatigue (91.4%) at the initial of referral to PC. This retrospective study, in a population of patients with advanced NSCLC, gave detailed information about PC services in a tertiary cancer center.

Timing of palliative care referral and aggressive cancer care toward the end-of-life in pancreatic cancer: a retrospective, single-center observational study

BackgroundPancreatic cancer is noted for its late presentation at diagnosis, limited prognosis and physical and psychosocial symptom burden. This study examined associations between timing of palliative care referral (PCR) and aggressive cancer care received by pancreatic cancer patients in the last 30 days of life through a single health service.MethodA retrospective cohort analysis of end-of-life (EOL) care outcomes of patients with pancreatic cancer who died between 2012 and 2016. Key indicators of aggressive cancer care in the last 30 days of life used were: ≥1 emergency department (ED) presentations, acute inpatient/intensive care unit (ICU) admission, and chemotherapy use. We examined time from PCR to death and place of death. Early and late PCR were defined as > 90 and ≤ 90 days before death respectively.ResultsOut of the 278 eligible deaths, 187 (67.3%) were categorized as receiving a late PCR and 91 (32.7%) an early PCR. The median time between referral and death was 48 days. Compared to those receiving early PCR, those with late PCR had: 18.1% (95% CI 6.8–29.4%) more ED presentations; 12.5% (95% CI 1.7–24.8%) more acute hospital admissions; with no differences in ICU admissions. Pain and complications of cancer accounted for the majority of overall ED presentations. Of the 166 patients who received chemotherapy within 30 days of death, 23 (24.5%) had a late PCR and 12 (16.7%) an early PCR, with no association of PCR status either unadjusted or adjusted for age or gender. The majority of patients (55.8%) died at the inpatient palliative care unit.ConclusionOur findings reaffirm the benefits of early PCR for pancreatic cancer patients to avoid inappropriate care toward the EOL. We suggest that in modern cancer care, there can sometimes be a need to reconsider the use of the term ‘aggressive cancer care’ at the EOL when the care is appropriately based on an individual patient’s presenting physical and psychosocial needs. Pancreatic cancer patients warrant early PCR but the debate must thus continue as to how we best achieve and benchmark outcomes that are compatible with patient and family needs and healthcare priorities.

1514PD - Timing of palliative care referral before and after a cluster randomized controlled trial (RCT) of early palliative care

1514PD - Timing of palliative care referral before and after a cluster randomized controlled trial (RCT) of early palliative care

It's Time to Talk: Challenges in Providing Integrated Palliative Care in Advanced Congestive Heart Failure. A Narrative Review.

Background:Congestive heart failure is an increasingly prevalent terminal illness in a globally aging population. Prognosis for this disease remains poor despite optimal therapy. Evidence suggests that a palliative care approach may be beneficial – and is currently recommended – in advanced congestive heart failure but these services remain underutilized.Objectives:To identify the main challenges to the access and delivery of palliative care in patients with advanced congestive heart failure, and to summarize recommendations for clinical practice based on the available literature.Methods:MEDLINE and EMBASE were searched for articles published from 1995-2017 pertaining to end of life care in individuals suffering from CHF. Only four randomized controlled trials were found.Results:We identified ten key challenges to access and delivery of palliative care services in this patient population: (1) Prognostic uncertainty, (2) Provider education/training, (3) Ambiguity surrounding coordination of care, (4) Timing of palliative care referral, (5) Inadequate community supports, (6) Difficulty communicating uncertainty, (7) Fear of taking away hope, (8) Insufficient advance care planning, (9) Inadequate understanding of illness, and (10) Discrepant patient/family care goals. Provider and patient education, early discussion about prognosis, and a multidisciplinary team-based approach are recommended as we move towards a model where symptom palliation exists concurrently with active disease-modifying therapies.Conclusion:Despite evidence that palliative care may improve symptom control and quality of life in patients with advanced congestive heart failure, a multitude of current challenges hinder access to these services. Education, early discussion of prognosis and advance care planning, and multidisciplinary team-based care may be a helpful initial approach as further targeted work addresses these challenges.

Patterns of palliative care referral in ovarian cancer: A single institution 5 year retrospective analysis

BackgroundThe American Society of Clinical Oncology recommends that patients with advanced cancer receive dedicated palliative care services early in their disease course. This investigation serves to understand how palliative care services are utilized for ovarian cancer patients in a tertiary referral center. MethodsWe conducted a retrospective review of women treated for ovarian cancer at our institution from 2010 through 2015. Clinical variables included presence and timing of palliative care referral. Data were correlated utilizing univariable and multivariable parametric and non-parametric testing, and survivals were analyzed using the Kaplan-Meier method and cox-proportional hazard models. ResultsWe identified 391 women treated for ovarian cancer, of whom 68% were diagnosed with stage III or IV disease. Palliative care referral was utilized in 28% in the outpatient (42%) and inpatient (58%) settings. Earlier use of referral was observed in those who never underwent surgical cytoreduction or had interval cytoreductive surgery (p < 0.001). Palliative care referral was independently associated with advanced stage (OR 1.7, p = 0.02), recurrence (OR 2.0, p = 0.002) and hospice referral (OR 6.0, p < 0.001). In 38% of women referral occurred within 30 days of death, and 17% within one week of death. Outpatient initial consultation was associated with an unadjusted 1 year overall survival benefit (p < 0.01) compared to inpatient consultation. ConclusionsThe outcomes in this study suggest a late use of palliative care that is reactionary to patient needs and not a routine component of ovarian cancer care as national guidelines recommend.

Setting and timing of end-of-life care in cancer patients.

e21502 Background: Limited data are available on how the setting and timing of palliative care (PC) referral can affect end-of-life (EoL) care and survival in cancer patients (pts). The aim of our study was to evaluate the impact of PC referral (hospice and/or home-care services) versus family physician care (FP-C), in terms of both EoL quality of care and survival in cancer pts. Methods: The study included 337 cancer pts who died between January 2015 and February 2016. We retrieved data on type of EoL care and on poor quality of care indicators in the last 30 days of life. Palliative Care Survival (PCS) was defined as the interval between timing of PC referral and death. The survival after treatment (Treatment-Free Survival, TFS) was defined as the interval between the last administration of anticancer therapy and death. Results: FP-C court included 89 pts and PC services court 248 pts. The 248 PC pts were divided in three groups: 99 assisted by both PC services, 58 only by home-care and 91 only by hospice care. The median PCS was 24 days. TFS was significantly longer for the three groups assisted by PC (105, 95, and 82 days respectively) than for that assisted only by FP-C (49 days, p &lt; 0.0001). Compared to PC services, FP-C was associated with higher frequency of poor quality of care indicators, such as emergency room visits (p &lt; 0.0001), hospitalizations (p &lt; 0.0001), hospital death (p &lt; 0.0001) and chemotherapy administration (p &lt; 0.0001). In addition, earlier PC referral (30-60 and &gt; 60 days before death) versus late referral ( &lt; 30 days before death) was associated with a lower frequency of poor quality indicators. Variables such as age, sex and primary tumor were not associated with a different quality of care. Conclusions: Pts referred to PC services, compared to pts referred only to FP-C, had improved EoL survival and quality of care. A better definition of PC referral timing can affect the quality of EoL care in cancer pts.

369O Timing of palliative care referral and its impact on receiving aggressive end of life care in patients with metastatic non-small cell lung cancer (NSCLC) in Southwest Sydney

369O Timing of palliative care referral and its impact on receiving aggressive end of life care in patients with metastatic non-small cell lung cancer (NSCLC) in Southwest Sydney

Timing of referral to inpatient palliative care services for advanced cancer patients and earlier referral predictors in mainland China.

Routine early integration of palliative care with advanced cancer management is not yet a part of standard practice in many countries, including mainland China. Whether patients in China suffering from advanced cancer are referred to palliative care services in a timely manner remains unclear. We sought to investigate the timing of palliative care referral of Chinese cancer patients at our center and its predictors. Retrospective medical data including demographic characteristics and referral information were collected for analysis. A total of 759 patients referred to our palliative care unit (PCU) from January of 2007 to December of 2013 were included in the final analysis. The mean age of the 759 patients included in the study was 62.89 years (range 61.95-63.82). Some 369 patients (48.6%) were male and 559 (73.6%) Shanghainese (indigenous). Lung cancer (17.9%) was the most common diagnosis. The time interval since enrollment into the PCU until a patient's death (length of stay, LOS) was calculated. A longer LOS indicated earlier referral to inpatient PC services. The median LOS was 21 days (CI 95% = 19.79-22.21). Multivariate analysis showed that whether or not the patient was indigenous (p = 0.002) and younger than 65 (p = 0.031) were independent factors for a longer LOS. Such other characteristics as gender and primary cancer type bore no relationship to LOS. Our findings demonstrate that Chinese cancer patients are referred relatively late in the course of their disease to inpatient palliative care services. To overcome the barriers to early integration of palliative care into a patient's treatment plan, accurate information about palliative care must be provided to both oncologists and patients via comprehensive and systematic educational programs.

Predictors of early referral of advanced cancer patients to an outpatient palliative care specialty clinic in a tertiary cancer hospital.

136 Background: Integration of palliative care (PC) with oncologic care has been advocated. In recent years our group has observed increased referral of cancer patient in earlier stages of illness. Our study objective was to compare clinical characteristics of advanced cancer (aCA) patients referred by their oncologists within 2 months of aCA diagnosis (early referral, ER) versus those referred more than 2 months later (late referral, LR). Methods: We collected data on baseline characteristics, symptoms, and the timing of PC referral on consecutive cancer patients seen in first consultation at the outpatient PC specialty clinic in fiscal year 2013. Results: Of the 1225 cancer patients referred for PC consultation, 968 (79%) patients had aCA, of which 38% (n = 372) were seen as ER, and 62% (n = 596) as LR. As compared to the LR group, patients in the ER group had significantly higher severity of pain, SOB, anxiety and drowsiness. In the ER group, a significantly higher proportion of patients had aCA status at initial presentation to their oncologist as compared to the LR group (83% versus 60%; p &lt; 0.0001). Of all the referring primary services, Thoracic Medicine was the only service where a majority of aCA patients were in the ER group (161 versus 122 patients; p &lt; 0.05). In regression analysis, the odds of patients being referred early was higher if they belonged to the Thoracic Medicine service, had aCA at initial presentation to their oncologist, and had higher severity of fatigue and drowsiness. Overall, the median survival of aCA patients, calculated from date of PC consultation, was 5.9 months, and did not differ between ER and LR groups (6.1 and 5.8 months; log-rank 0.832). Conclusions: Our study demonstrates that oncologist’s decision to refer patients early to PC clinic depends on the type of primary service, having advanced stage disease at initial presentation, presence of symptoms of fatigue and drowsiness, and prognostication of decreased survival. The median survival time of 6 months from PC consultation is encouraging and suggests earlier PC referral of cancer patients as compared to earlier reports.