State of palliative care services at US cancer centers: An updated national survey

A month of diagnostic imaging studies in an acute supportive/palliative care unit

AIM

The aim was to assess the characteristics of patients who required imaging studies during admission to an acute supportive palliative care unit (ASPCU).

METHODS

A consecutive number of patients who performed imaging studies during ASPCU admission in a month period were assessed. Epidemiological data, ongoing anticancer treatment, cancer diagnosis, reasons for admission, referral, and type of imaging study were recorded. Indications, findings, consequent actions for treatment, prognosis, and discharge were also collected.

RESULTS

Twenty-one of 56 patients admitted to ASPCU in the period taken into consideration were assessed. Pain and deterioration of the general condition were the most frequent indications for admission. Computed tomography (CT) was the most frequent imaging study performed. Indications for performing imaging studies depended on individual clinical needs. Findings suggested different clinical decisions, after a comprehensive oncological and palliative care assessment and family conference, the most frequent of which was to withdraw oncological treatments. The majority of patients underwent transition to palliative care and were discharged home or to hospice.

CONCLUSION

Imaging studies were of paramount importance for clinical treatment and decision-making process in an intensive ASPCU. There is the need to explore the need and the possible outcomes of imaging studies, as well cost-effectiveness in any ASPCU.

Provider Perspectives and Access to Palliative Care: An American Head and Neck Society (AHNS) Survey

BACKGROUND

To explore provider perspectives about palliative care (PC) in head and neck cancer (HNC) care.

METHODS

A 25-question electronic survey was disseminated to the membership of the American Head and Neck Society (AHNS) from April 10, 2023, through June 13, 2023.

RESULTS

Respondents were most likely to refer to PC at symptomatic disease progression (52%) or terminal diagnosis (29%) rather than at initial diagnosis (17%). Participants less likely to refer to PC were less likely to refer to symptomatic progression (8% vs. 39%, p = 0.0006) or address advance directives (62% vs. 87%, p = 0.0406). Symptom burden questionnaires were used by only 29% of respondents. Discordance was identified between self-reported and actual access to local inpatient and outpatient PC services.

CONCLUSIONS

Barriers to PC identified include a lack of established optimal timing of PC referral, a perceived lack of local access to PC, and a lack of uniform standardized assessment of symptom burden.

Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

BACKGROUND

Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care (PC) evaluations in patients undergoing high-risk vascular operations.

METHODS

A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), PC evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of PC prior to death was noted. Patients who received ACP or PC were compared with those who did not.

RESULTS

The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (standard deviation [SD] 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n = 32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with do not resuscitate and/or intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n = 2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had ACP documentation and 7 (3.7%) of patients underwent PC evaluation. Fifteen percent of patients (n = 28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n = 8 out of 28) received PC. Overall, 28.6% of all study patients that died (n = 14 out of 49) received a PC evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received PC consultations prior to surgery were older (P = 0.01), more likely to be on Medicare or Medicaid (P = 0.004), and more likely to have a history of solid organ malignancy (P = 0.03). The median interval between surgery and receiving PC was 20 (interquartile range [IQR] 3-71) days. The median interval between PC and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (P = 0.05).

CONCLUSIONS

Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. PC interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.

Clinician perspectives on delivering primary and specialty palliative care in community oncology practices

PURPOSE

Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities.

METHODS

Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment.

RESULTS

Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%).

CONCLUSION

Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.

Clinician Insights into Effective Components, Delivery Characteristics and Implementation Strategies of Ambulatory Palliative Care for People with Heart Failure: A Qualitative Analysis

OBJECTIVES

To elicit perspectives from specialist palliative care (SPC) and cardiology clinicians concerning the necessary components, delivery characteristics and implementation strategies of successful ambulatory SPC for people with heart failure (HF).

BACKGROUND

Palliative care is a recommended component of guideline-directed care for people with HF. However, optimal strategies to implement SPC within ambulatory settings are unknown.

METHODS

We conducted a qualitative descriptive study composed of semistructured interviews with SPC and cardiology clinicians at Veterans Affairs Medical Centers (VAMCs) with the highest number of ambulatory SPC consultations within the VA system among people with HF between 2021 and 2022. Clinicians were asked how they provided ambulatory SPC and what they felt were the necessary components, delivery characteristics and implementation strategies of care delivery. Interviews were analyzed using directed content analysis.

RESULTS

We interviewed 14 SPC clinicians and 9 cardiology clinicians at 7 national VAMCs; 43% were physicians, and 48% were advanced-practice registered nurses/physician associates. Essential components of ambulatory SPC encompassed discussion of goals of care (eg, prognosis, advance directives) and connecting patients/caregivers to resources (eg, home care). Preferred delivery characteristics included integrated (ie, embedded) approaches to SPC delivery, standardized patient selection and referral procedures, and formalized procedures for handoffs to and from SPC. Strategies that addressed SPC implementation included deploying palliative champions, educating non-SPC clinicians on the value of ambulatory SPC for people with HF and developing ambulatory models through leadership support.

CONCLUSIONS/IMPLICATIONS

Facilitating the broader adoption of ambulatory SPC among people with HF may be achieved by prioritizing these mutually valued and necessary features of SPC delivery.

Palliative Care for Patients With Cancer: ASCO Guideline Update

PURPOSE

To provide evidence-based guidance to oncology clinicians, patients, nonprofessional caregivers, and palliative care clinicians to update the 2016 ASCO guideline on the integration of palliative care into standard oncology for all patients diagnosed with cancer.

METHODS

ASCO convened an Expert Panel of medical, radiation, hematology-oncology, oncology nursing, palliative care, social work, ethics, advocacy, and psycho-oncology experts. The Panel conducted a literature search, including systematic reviews, meta-analyses, and randomized controlled trials published from 2015-2023. Outcomes of interest included quality of life (QOL), patient satisfaction, physical and psychological symptoms, survival, and caregiver burden. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 52 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Evidence-based recommendations address the integration of palliative care in oncology. Oncology clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of the disease, alongside active treatment of their cancer. For patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services complementing existing or emerging supportive care interventions. Oncology clinicians from across the interdisciplinary cancer care team may refer the caregivers (eg, family, chosen family, and friends) of patients with cancer to palliative care teams for additional support. The Expert Panel suggests early palliative care involvement, especially for patients with uncontrolled symptoms and QOL concerns. Clinicians caring for patients with solid tumors on phase I cancer trials may also refer them to specialist palliative care.Additional information is available at www.asco.org/supportive-care-guidelines.

Outpatient Training During Hospice and Palliative Medicine Fellowship: A National Survey

CONTEXT

Outpatient palliative care (PC) has strong evidence demonstrating impact across serious illnesses, resulting in growing demand for skilled outpatient PC clinicians. However, there is limited literature examining the existing state and quality of outpatient PC education during postgraduate training.

OBJECTIVES

Characterize the current state of outpatient training in United States (US) Hospice and Palliative Medicine (HPM) physician fellowships and elicit perceptions regarding quality of outpatient PC education.

METHODS

A cross-sectional survey of US adult HPM fellowship program directors (PDs) or their designee conducted between March and July, 2023.

RESULTS

Of 161 programs, 85 participated (53% response rate) with representation across all US regions. HPM fellows spend a median of 4.8 weeks in outpatient PC compared to 24 weeks inpatient PC and 10.5 weeks in hospice settings. Over half (51%) of fellows saw outpatients from primarily one disease type with limited exposure to patients with other serious illnesses. Across programs, fellows' clinic structure, interdisciplinary team composition, and didactic experiences varied. On a 5-point rating scale, PDs reported significantly lower quality outpatient versus inpatient training (mean rating: 3.58 vs. 4.62, P<0.001) and perceived fellows as less prepared for independent outpatient practice upon graduation (mean: 4.06 vs. 4.73, P<0.001).

CONCLUSION

Our survey of US HPM fellowships identified multiple gaps between outpatient and inpatient PC education and training during fellowship and raises concern about the adequacy of outpatient PC training. To prepare the HPM workforce to meet the diverse needs of seriously ill populations and ensure adequate access, outpatient PC training requires reform.

Transformative Peer Connections: Early Experiences From the ASCO Palliative Care Community of Practice

The integration of palliative care into routine oncology practice is the standard of care by most leading cancer organizations. Palliative medicine helps to deliver higher quality of care at a lower cost. However, there are barriers to implementing palliative oncology at many institutions for myriad reasons. In this article, we discuss an innovative strategy that ASCO implemented called the Communities of Practice (CoP). We share our experiences as the Palliative Care CoP and how our group seeks to develop processes and structures to collectively promote systemic change and enhance palliative care delivery for people with cancer. Our Palliative Care CoP engages with senior leaders, administrators, and those in power to achieve a shared vision of delivering holistic health care for people with serious illness. We continue to evolve to meet our members' growing needs by addressing eight main domains: (1) increasing palliative care education and resources; (2) creating opportunities for global palliative care research; (3) providing peer mentorship and community building; (4) engaging with patient advocates; (5) supporting and developing interdisciplinary teams; (6) assisting with professional development and identity formation, especially for trainees and early career faculty; (7) extending our outreach through social media; and (8) enhancing the clinical practice of palliative oncology. The ASCO CoP has been a vital forum to realize ASCO's mission of conquering cancer and advancing the Art and Science of Cancer Care: From Comfort to Cure.

Why and How to Integrate Early Palliative Care Into Cutting-Edge Personalized Cancer Care

Early palliative care, palliative care integrated with oncology care early in the course of illness, has myriad benefits for patients and their caregivers, including improved quality of life, reduced physical and psychological symptom burden, enhanced prognostic awareness, and reduced health care utilization at the end of life. Although ASCO and others recommend early palliative care for all patients with advanced cancer, widespread implementation of early palliative care has not been realized because of barriers such as insufficient reimbursement and a palliative care workforce shortage. Investigators have recently tested several implementation strategies to overcome these barriers, including triggers for palliative care consultations, telehealth delivery, navigator-delivered interventions, and primary palliative care interventions. More research is needed to identify mechanisms to distribute palliative care optimally and equitably. Simultaneously, the transformation of the oncology treatment landscape has led to shifts in the supportive care needs of patients and caregivers, who may experience longer, uncertain trajectories of cancer. Now, palliative care also plays a clear role in the care of patients with hematologic malignancies and may be beneficial for patients undergoing phase I clinical trials and their caregivers. Further research and clinical guidance regarding how to balance the risks and benefits of opioid therapy and safely manage cancer-related pain across this wide range of settings are urgently needed. The strengths of early palliative care in supporting patients' and caregivers' coping and centering decisions on their goals and values remain valuable in the care of patients receiving cutting-edge personalized cancer care.

Subcutaneous administration of drugs and hydration in acute palliative care units: Physician attitudes and beliefs in the United States and Canada

OBJECTIVES

The objective of this study was to compare the attitudes and beliefs of PCU physicians leaders in the United States versus Canada regarding the subcutaneous method in the administration of medications and hydration in order to gain a better understanding as to why variations in practice exist.

METHODS

This survey trial took place from November 2022 to May 2023. The MD Anderson Cancer Center institutional review board in Houston, Texas, approved this study. The participants were the physician leaders of the acute palliative care units (PCUs) in the United States and Canada. The survey comprised questions formulated by the study investigators regarding the perceived comfort, efficiency, and preference of using the subcutaneous versus the intravenous method. The consent form and survey links were emailed to the participants.

RESULTS

Sixteen PCUs were identified in the United States and 15 PCUs in Canada. Nine US and 8 Canadian physicians completed the survey. Physicians in Canada were more likely to use the subcutaneous route for administering opioids, antiemetics, neuroleptics, and hydration. They preferred subcutaneous over intravenous or intramuscular routes (p = 0.017). Canadian physicians felt their nursing staff was more comfortable with subcutaneous administration (p = 0.022) and that it was easier to administer (p = 0.02). US physicians felt the intravenous route was more efficient (p = 0.013).

SIGNIFICANCE OF RESULTS

The study results suggest that exposure to the subcutaneous route influences a physician's perception. Further research is needed to explore ways to incorporate its use to a greater degree in the US healthcare system.

The impact of outpatient supportive oncology on cancer care cost and utilization

BACKGROUND

Supportive oncology (SO) care reduces symptom severity, admissions, and costs in patients with advanced cancer. This study examines the impact of SO care on utilization and costs.

METHODS

Retrospective analysis of utilization and costs comparing patients enrolled in SO versus three comparison cohorts who did not receive SO. Using claims, the authors estimated differences in health care utilization and cost between the treatment group and comparison cohorts. The treatment group consisting of patients treated for cancer at an National Cancer Institute-designated cancer center who received SO between January 2018 and December 2019 were compared to an asynchronous cohort that received cancer care before January 2018 (n = 60), a contemporaneous cohort with palliative care receiving SO care from other providers in the Southeastern Pennsylvania region during the program period (n = 86), and a contemporaneous cohort without palliative care consisting of patients at other cancer centers who were eligible for but did not receive SO care (n = 393).

RESULTS

At 30, 60, and 90 days post-enrollment into SO, the treatment group had between 27% and 70% fewer inpatient admissions and between 16% and 54% fewer emergency department visits (p < .05) compared to non-SO cohorts. At 90 days following enrollment in SO care, total medical costs were between 4.4% and 24.5% lower for the treatment group across all comparisons (p < .05).

CONCLUSIONS

SO is associated with reduced admissions, emergency department visits, and total costs in advanced cancer patients. Developing innovative reimbursement models could be a cost-effective approach to improve care of patients with advanced cancer.

Role of Palliative Care in the Supportive Management of AL Amyloidosis-A Review

Light chain amyloidosis is a plasma-cell disorder with a poor prognosis. It is a progressive condition, causing worsening pain, disability, and life-limiting complications involving multiple organ systems. The medical regimen can be complex, including chemotherapy or immunotherapy for the disease itself, as well as treatment for pain, gastrointestinal and cardiorespiratory symptoms, and various secondary symptoms. Patients and their families must have a realistic awareness of the illness and of the goals and limitations of treatments in making informed decisions about medical therapy, supportive management, and end-of-life planning. Palliative care services can thus improve patients' quality of life and may even reduce overall treatment costs. Light chain (AL) amyloidosis is a clonal plasma cell disorder characterized by the excessive secretion of light chains by an indolent plasma cell clone that gradually accumulates in vital organs as amyloid fibrils and leads to end-organ damage. With progressive disease, most patients develop diverse clinical symptoms and complications that negatively impact quality of life and increase mortality. Complications include cardiac problems including heart failure, hypotension, pleural effusions, renal involvement including nephrotic syndrome with peripheral edema, gastrointestinal symptoms leading to anorexia and cachexia, complex pain syndromes, and mood disorders. The prognosis of patients with advanced AL amyloidosis is dismal. With such a complex presentation, and high morbidity and mortality rates, there is a critical need for the establishment of a palliative care program in clinical management. This paper provides an evidence-based overview of the integration of palliative care in the clinical management of AL amyloidosis as a means of reducing ER visits, rehospitalizations, and in-hospital mortality. We also discuss potential future collaborative directions in various aspects of clinical care related to AL amyloidosis.

Palliative Care as a Component of High-Value and Cost-Saving Care During Hospitalization for Metastatic Cancer

PURPOSE

Randomized controlled trials have demonstrated that palliative care (PC) can improve quality of life and survival for outpatients with advanced cancer, but there are limited population-based data on the value of inpatient PC. We assessed PC as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer and identified hospitalization characteristics significantly associated with high costs.

METHODS

Hospitalizations of patients 18 years and older with a primary diagnosis of metastatic cancer from the National Inpatient Sample from 2010 to 2019 were analyzed. We used multivariable mixed-effects logistic regression to assess medical services, patient demographics, and hospital characteristics associated with higher charges billed to insurance and hospital costs. Generalized linear mixed-effects models were used to determine cost savings associated with provision of PC.

RESULTS

Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in US dollars (USD) to $56,098 USD, whereas the median hospital cost remained stable at $14,300 USD. Receipt of inpatient PC was associated with significantly lower charges (odds ratio [OR], 0.62 [95% CI, 0.61 to 0.64]; P < .001) and costs (OR, 0.59 [95% CI, 0.58 to 0.61]; P < .001). Factors associated with high charges were receipt of invasive medical ventilation (P < .001) or systemic therapy (P < .001), Hispanic patients (P < .001), young age (18-49 years, P < .001), and for-profit hospitals (P < .001). PC provision was associated with a $1,310 USD (-13.6%, P < .001) reduction in costs per hospitalization compared with no PC, independent of the receipt of invasive care and age.

CONCLUSION

Inpatient PC is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Integration of inpatient PC may de-escalate costs incurred through low-value inpatient interventions.

Integration of Psychosocial Theory into Palliative Care: Implications for Care Planning and Early Palliative Care

Palliative care improves patients' symptoms, quality of life and family satisfaction with caregiving, reduces hospital admissions and promotes alignment of medical care with the patient's needs and goals. This article proposes the utility of integrating three psychosocial theories into standard palliative care with implications for care planning, early palliative care and optimizing quality of life. First, Control Theory focuses on the complex juxtaposition of promoting agency/empowerment in patients and carers and coping with often highly uncertain outcomes. Second, Optimal Matching Theory accounts for the alignment of need and provision of care to potentiate the quality of life effects of supportive care in a complex social process involving health care providers, patients and carers. Third, Hope Theory represents a dynamic process, which is marked by variation in the qualities of hope as the patient and carer confront challenges during palliative care. Future work will be translational in nature to adapt both assessment and interventions based on this theoretically driven augmentation of palliative care as well as to evaluate whether it provides a conceptual framework that has incremental utility in palliative care planning.

One third of physicians discuss exit strategies with patients with amyotrophic lateral sclerosis: Results from nationwide surveys among German and Polish neurologists

OBJECTIVE

This paper examines neurologists' approaches to exit strategies (ESs), such as euthanasia and physician-assisted suicide, in patients with amyotrophic lateral sclerosis (PALS) in two European countries.

METHODS

In a nationwide anonymous survey, we collected responses from 237 Polish and 228 German neurologists, focusing on their practices and beliefs about ESs, as well as their viewpoints on life-sustaining measures (LSMs) (percutaneous endoscopic gastrostomy, non-invasive, and invasive ventilation). To analyze the data, we employed statistical methods, including Mann-Whitney U, Kruskal-Wallis, chi-square tests, Spearman's rank correlation, and multiple regression analysis.

RESULTS

One third of the neurologists initiated the discussion about ESs with PALS. Half were ready to have this conversation upon patient's request. Age, gender, religiousness, and nationality were closely associated with this approach. One in 9 neurologists received a request to terminate an LSM, whereas 1 in 10 to implement an ES. German neurologists and palliative care trainees acquired both demands more commonly. Neurologists quoted a low quality of life, decreased mood, and being a burden to the family/closest ones as primary reasons for a wish to hasten death among PALS. Although the majority expressed a willingness to terminate an LSM at a request of the patient, most opposed the legalization of euthanasia. Younger and less religious individuals were more likely to favor accepting euthanasia.

CONCLUSION

Neurologists vary significantly in their approaches to terminal care. Complex relationships exist among personal indices, shared beliefs, and current practices.

Developing a national implementation strategy to accelerate uptake of evidence-based family caregiver support in U.S. cancer centers

OBJECTIVE

Characterize key factors and training needs of U.S. cancer centers in implementing family caregiver support services.

METHODS

Sequential explanatory mixed methods design consisting of: (1) a national survey of clinicians and administrators from Commission-on-Cancer-accredited cancer centers (N = 238) on factors and training needed for establishing new caregiver programs and (2) qualitative interviews with a subsample of survey respondents (N = 30) to elicit feedback on survey findings and the outline of an implementation strategy to facilitate implementation of evidence-based family caregiver support (the Caregiver Support Accelerator). Survey data was tabulated using descriptive statistics and transcribed interviews were analyzed using thematic analysis.

RESULTS

Top factors for developing new caregiver programs were that the program be: consistent with the cancer center's mission and strategic plan (87%), supported by clinic leadership (86.5%) and providers and staff (85.7%), and low cost or cost effective (84.9%). Top training needs were how to: train staff to implement programs (72.3%), obtain program materials (63.0%), and evaluate program outcomes (62.6%). Only 3.8% reported that no training was needed. Qualitative interviews yielded four main themes: (1) gaining leadership, clinician, and staff buy-in and support is essential; (2) cost and clinician burden are major factors to program implementation; (3) training should help with adapting and marketing programs to local context and culture; and (4) the Accelerator strategy is comprehensive and would benefit from key organizational partnerships and policy standards.

CONCLUSION

Findings will be used to inform and refine the Accelerator implementation strategy to facilitate the adoption and growth of evidence-based cancer caregiver support in U.S. cancer centers.

Mortality rate and palliative sedation in an acute palliative care unit

AIM

To assess the mortality rate and the use of palliative sedation (PS) in an advanced long-standing acute palliative care unit (APCU) METHODS: The charts of patients who died and eventually received PS, consecutively admitted to the APCU for 4 years, were reviewed. Patients' characteristics and symptom intensity were recorded at admission, 3 days before death and the day before death (T0, T-3, T-end, respectively). For patients who were administered midazolam for PS, initial and final doses of drugs, as well as duration of PS until death, were recorded.

RESULTS

One hundred and forty-eight patients died in APCU (8.9%), and 45 of them (30.4%) received PS. Younger patients and those reporting high levels of dyspnoea at T-3 and T-end were more likely to be sedated (p=0.002, p=0.013 and 0.002, respectively). The mean duration of PS was 27.47 hours. Mean initial and final doses of midazolam were 35.45 mg/day (SD 19.7) and 45.57 mg/day (SD 20.6), respectively (p=0.001).

CONCLUSION

Mortality rate in APCU was very low. As a percentage of the number of deaths, PS rate was similar to that reported in other settings. PS does not seem to accelerate impending death.

Acute palliative care units: characteristics, activities and outcomes - scoping review

Acute palliative care units (APCUs) are lacking in most cancer hospitals and even when palliative care units are present, they are predominantly based on a traditional hospice-like model for patients with short life expectancy. This scoping review examined the papers assessing the activities of APCU. Data from literature regarding APCU characteristics, activities and outcomes have shown important differences among different countries.In comparison with existing data on traditional hospices, APCU provided a whole range of palliative care interventions, from an early treatment of pain and symptoms at time diagnosis and during the oncological treatment, up to the advanced stage of disease when they may favour the transition to the best supportive care or palliative care only, also indicating the best palliative care service that may fits the clinical and social condition of individuals. Large differences in the characteristics of such units, including hospital stay and mortality, have been evidenced, in some cases resembling those of a traditional hospice. It likely that in some countries such units supply the lack of other palliative care services.Further studies on APCUs are needed, even on other outcome processes, to provide a more precise identification among the palliative care settings, which should not interchangeable, but complimentary to offer the full range of activities to be activated according to the different needs of the patients.

Incorporation of Palliative Care in Gynecologic Oncology

PURPOSE OF REVIEW

This review serves to provide clarity on the nature, scope, and benefits of early palliative care integration into the management of patients with gynecologic malignancies.

RECENT FINDINGS

There is increased recognition that timely referral to palliative care improves quality of life for patients and their families by providing goal-concordant care that reduces physical and emotional suffering and limits futile and aggressive measures at the end of life. Palliative care services rendered throughout the continuum of illness ultimately increase engagement with hospice services and drive down health expenditures. Despite these myriad benefits, misconceptions remain, and barriers to and disparities in access to these services persist and warrant continued attention. Palliative care should be offered to all patients with advanced gynecologic cancers early in the course of their disease to maximize benefit to patients and their families.

Integrating palliative care into the evolving landscape of oncology

Patients with cancer have many palliative care needs. Robust evidence supports the early integration of palliative care into the care of patients with advanced cancer. International organizations, such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), have recommended early, longitudinal integration of palliative care into oncology care throughout the cancer trajectory. In this review, we pose a series of clinical questions related to the current state of early palliative care integration into oncology. We review the evidence to address each of these questions and highlight areas for further investigation. As cancer care continues to evolve, incorporating new treatment modalities and improving patient outcomes, we reflect on how to apply the existing evidence supporting early palliative care-oncology integration into this ever-changing therapeutic landscape and how specialty palliative care might adapt to meet the evolving needs of patients, caregivers, and the multidisciplinary oncology team.

National survey on the availability of oncology palliative care services at tertiary general and cancer hospitals in China

BACKGROUND

This nationwide survey studied the level of palliative care (PC) access for Chinese patients with cancer among cancer care providers either in tertiary general hospitals or cancer hospitals in China.

METHODS

Using a probability-proportionate-to-size method, we identified local tertiary general hospitals with oncology departments to match cancer hospitals at the same geographic area. A PC program leader or a designee at each hospital reported available PC services, including staffing, inpatient and outpatient services, education, and research, with most questions adapted from a previous national survey on PC. The primary outcome was availability of a PC service.

RESULTS

Most responders reported that some type of PC service (possibly called "comprehensive cancer care," "pain and symptom management," or "supportive care") was available at their institution (84.3% of tertiary general hospitals, 82.8% of cancer hospitals). However, cancer hospitals were significantly more likely than tertiary general hospitals to have a PC department or specialist (34.1% vs. 15.5%, p < 0.001). The most popular services were pain consultation (> 92%), symptom management (> 77%), comprehensive care plans (~ 60%), obtaining advanced directives and do-not-resuscitate orders (~ 45%), referrals to hospice (> 32%), and psychiatric assessment (> 25%). Cancer hospitals were also more likely than tertiary general hospitals to report having inpatient beds for PC (46.3% vs. 30.5%; p = 0.010), outpatient PC clinics (28.0% vs. 16.8%; p = 0.029), educational programs (18.2% vs. 9.0%, p = 0.014), and research programs (17.2% vs. 9.3%, p < 0.001).

CONCLUSIONS

Cancer hospitals are more likely to offer PC than are tertiary general hospitals in China. Our findings highlight opportunities to further increase the PC capacity in Chinese hospitals.

Improving Access to Early Palliative Care Delivery for Patients With an Advanced Thoracic Malignancy Through an Embedded Oncopalliative Clinic Model

PURPOSE

Early integration of palliative care (PC) with standard oncology care is driving the development of innovative PC delivery models.

METHODS

This was a single-institution retrospective study of outpatient PC before and after the opening of an embedded thoracic oncology-palliative clinic at The Ohio State University. Patients included in the preintervention (October 2017-July 2018) and postintervention (October 2018-July 2019) cohorts had a diagnosis of any non-small-cell lung cancer (stages I-IV) or small-cell lung cancer (limited or extensive stage) and were newly established in the thoracic medical oncology clinic during the study time periods. All patients in the preintervention cohort had access to outpatient PC through a freestanding clinic, while the postintervention cohort had access to both freestanding and embedded clinics. Using time-to-event analyses, we evaluated differences in time intervals from first medical oncology visit to PC referral and first PC visit between cohorts.

RESULTS

The majority of patients in both cohorts had metastatic disease at diagnosis. In the postintervention cohort, 20.9% of patients were referred to outpatient PC compared with 9.2% in the preintervention cohort (P < .01). PC referrals for patients outside of Franklin and adjacent counties increased from 4.0% to 14.2% after opening the embedded clinic (P < .01). Completion percentages of PC referrals increased from 57.6% to 76.0% in the preintervention versus postintervention cohorts (P = .048). Median time from palliative referral order to first PC visit decreased from 29 to 20 days (P = .047). Similarly, median time from the first oncology visit to PC referral completion decreased from 103 to 41 days (P = .08).

CONCLUSION

Implementation of an embedded PC model was associated with increased access to early PC among patients with thoracic malignancies.

Palliative Care Physicians' Perceptions of Conditions Required to Provide Early Palliative Care

CONTEXT

Early palliative care (EPC) is widely recommended but its implementation may be challenging.

OBJECTIVES

We conducted a qualitative analysis of Canadian palliative care physicians' opinions about conditions necessary to provide EPC.

METHODS

A survey assessing attitudes and opinions regarding EPC was distributed to physicians providing primary or specialized palliative care, as identified by the Canadian Society of Palliative Care Physicians. The survey included an optional final section for respondents' general comments; we screened these for relevance to our study aims and conducted a thematic analysis of relevant comments.

RESULTS

Of 531 completed surveys, 129 (24%) respondents provided written comments, of whom 104 mentioned conditions they felt to be necessary to provide EPC. Four key themes were identified: 1) Clear delineation of roles of primary and specialized palliative care physicians-all physicians should be empowered to provide primary palliative care, with specialists providing additional support; 2) Shared care with needs-dependent referral-primary and specialized palliative care physicians should work collaboratively, with referral to specialized palliative care based on need rather than on prognosis; 3) Adequate resources to support primary palliative care-education, financial incentives, and collaboration with interdisciplinary team members such as nurses and specialized providers were specifically mentioned; 4) Addressing the misconception that palliative care equals end-of-life care-there was particular emphasis on education of both healthcare providers and the public.

CONCLUSION

Changes are necessary at the level of palliative care referral systems, providers, resources, and policy to enable implementation of EPC.

Clinician Perspectives on Palliative Care for People with Hepatocellular Carcinoma: Facilitators of and Barriers to Referral

(1) Background: Little is known about facilitators of and barriers to palliative care referral for people with hepatocellular carcinoma (HCC). The objective of this study is to identify facilitators and barriers of palliative care referral described by HCC-treating clinicians. (2) Methods: Semi-structured interviews (n = 16) were conducted with HCC-treating clinicians at two centers, focusing on referral patterns, palliative care needs, and disease course. A code book was created, axial coding was used to code all interviews, and selective coding was used to identify facilitators and barriers of palliative care referral. (3) Results: Facilitators included helpfulness at times of transition; help with management of certain symptoms; provision of psychosocial support; and positive experiences with referral. Barriers included feasibility concerns; lack of information about palliative care and who is appropriate; lack of symptoms requiring outside referral; and concerns that palliative care conveys loss of hope. (4) Conclusions: Participants noted the helpfulness of palliative care at specific points in the disease trajectory and cited barriers related to feasibility, lack of need, lack of awareness, and loss of hope. The results show actionable issues that can be addressed in future research to leverage the benefits of and overcome the barriers to palliative care for people with HCC.

Palliative medicine integration in the USA: cancer centre executives' attitudes

OBJECTIVES

To compare cancer centre (CC) executives' attitudes towards palliative care between National Cancer Institute-designated CCs (NCI-CCs) and non-NCI-designated CCs (non-NCI-CCs) in 2018 and to examine the changes in attitudes and beliefs between 2009 and 2018.

METHODS

CC chief executives at all NCI-CCs and a random sample of non-NCI-CCs were surveyed from April to August 2018. Twelve questions examined the executives' attitudes towards palliative care integration, perceived barriers and self-assessments. The primary outcome was agreement on the statement 'a stronger integration of palliative care services into oncology practice will benefit patients at my institution.' Survey findings from 2018 were compared with data from 2009 to examine changes in attitudes.

RESULTS

52 of 77 (68%) NCI-CCs and 88 of 126 (70%) non-NCI-CCs responded to the survey. A vast majority of executives at NCI-CCs and non-NCI-CCs endorsed palliative care integration (89.7% vs 90.0%; p>0.999). NCI-CCs were more likely to endorse increasing funding for palliative care (52.5% vs 23.1%; p=0.01) and hiring physician specialists (70.0% vs 37.5%; p=0.004) than non-NCI-CCs. The top three perceived barriers among NCI-CCs and non-NCI-CCs were limited institutional budgets (57.9% vs 59.0%; p=0.92), poor reimbursements (55.3% vs 43.6%; p=0.31), and lack of adequately trained palliative care physicians and nurses (52.6% vs 43.6%; p=0.43). Both NCI-CCs and non-NCI-CCs favourably rated their palliative care services (89.7% vs 71.8%; p=0.04) with no major changes since 2009.

CONCLUSION

CC executives endorse integration of palliative care, with greater willingness to invest in palliative care among NCI-CCs. Resource limitation continues to be a major barrier.

Integrating Palliative Care into Oncology Care Worldwide: The Right Care in the Right Place at the Right Time

OPINION STATEMENT

While the benefits of early palliative care are indisputable, most of the current evidence has emerged from resource-rich settings in urban areas of high-income countries, with an emphasis on solid tumors in outpatient settings; this model of palliative care integration is not currently scalable internationally. A shortage of specialist palliative care clinicians means that in order to meet the needs of all patients who require support at any point along their advanced cancer trajectory, palliative care must also be provided by family physicians and oncology clinicians who require training and mentorship. Models of care that facilitate the timely provision of seamless palliative care across all settings (inpatient, outpatient, and home-based care), with clear communication between clinicians, are crucial to the provision of patient-centred palliative care. The unique needs of patients with hematological malignancies must be further explored and existing models of palliative care provision modified to meet these needs. Finally, care must be provided in an equitable and culturally sensitive manner, recognizing the challenges associated with the delivery of high-quality palliative care to both patients in high-income countries who live in rural areas, as well as to those in low- and middle-income countries. A one-size-fits-all model will not suffice, and there is an urgent need to develop innovative context-specific models of palliative care integration worldwide, in order to provide the right care, in the right place, and at the right time.

National Survey Using CFIR to Assess Early Outpatient Specialty Palliative Care Implementation

CONTEXT

The American Society of Clinical Oncology (ASCO) recommends that outpatient specialty palliative care (OSPC) be offered within eight weeks of an advanced cancer diagnosis. To meet the rising demand, there has been an increase in the availability of OSPC services at National Cancer Institute (NCI)-designated cancer centers; however, many OSPC referrals still occur late in the disease course.

OBJECTIVES

Using the Consolidated Framework for Implementation Research (CFIR), we evaluated facilitators and barriers to early OSPC implementation and associated clinic characteristics.

METHODS

We selected relevant CFIR constructs for inclusion in a survey that was distributed to the OSPC clinic leader at each NCI-designated cancer center. For each statement, respondents were instructed to rate the degree to which they agreed on a five-point Likert scale. We used descriptive statistics to summarize responses to survey items and explore differences in barriers based on OSPC clinic size and maturity.

RESULTS

Of 60 eligible sites, 40 (67%) completed the survey. The most commonly agreed upon barriers to early OSPC included inadequate number of OSPC providers (73%), lack of performance metric goals (65%), insufficient space to deliver early OSPC (58%), logistical challenges created by early OSPC (55%), and absence of formal interdisciplinary communication systems (53%). The most frequently reported barriers differed according to clinic size and maturity.

CONCLUSION

Most barriers were modifiable in nature and related to the "Inner Setting" domain of the CFIR, which highlights the need for careful strategic planning by leadership when implementing early OSPC.

Differential Impact of a Multicomponent Goals-of-Care Program in Patients with Hematologic and Solid Malignancies

We recently reported that an interdisciplinary multicomponent goals-of-care (myGOC) program was associated with an improvement in goals-of-care (GOC) documentation and hospital outcomes; however, it is unclear if the benefit was uniform between patients with hematologic malignancies and solid tumors. In this retrospective cohort study, we compared the change in hospital outcomes and GOC documentation before and after myGOC program implementation between patients with hematologic malignancies and solid tumors. We examined the change in outcomes in consecutive medical inpatients before (May 2019-December 2019) and after (May 2020-December 2020) implementation of the myGOC program. The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included GOC documentation. In total, 5036 (43.4%) patients with hematologic malignancies and 6563 (56.6%) with solid tumors were included. Patients with hematologic malignancies had no significant change in ICU mortality between 2019 and 2020 (26.4% vs. 28.3%), while patients with solid tumors had a significant reduction (32.6% vs. 18.8%) with a significant between-group difference (OR 2.29, 95% CI 1.35, 3.88; p = 0.004). GOC documentation improved significantly in both groups, with greater changes observed in the hematologic group. Despite greater GOC documentation in the hematologic group, ICU mortality only improved in patients with solid tumors.

Institution of Standardized Consultation Criteria to Increase Early Palliative Care Utilization in Older Patients With Acute Leukemia

PURPOSE

Older patients with acute leukemia (AL) have a high symptom burden and poor prognosis. Although integration of palliative care (PC) with oncologic care has been shown to improve quality-of-life and end-of-life care in patients with AL, the malignant hematologists at our tertiary care hospital make limited use of PC services and do so late in the disease course. Using the Plan-Do-Study-Act (PDSA) methodology, we aimed to increase early PC utilization by older patients with newly diagnosed AL.

METHODS

We instituted the following standardized criteria to trigger inpatient PC consultation: (1) age 70 years and older and (2) new AL diagnosis within 8 weeks. PC consultations were tracked during sequential PDSA cycles in 2021 and compared with baseline rates in 2019. We also assessed the frequency of subsequent PC encounters in patients who received a triggered inpatient PC consult.

RESULTS

The baseline PC consultation rate before our intervention was 55%. This increased to 77% and 80% during PDSA cycles 1 and 2, respectively. The median time from diagnosis to first PC consult decreased from 49 days to 7 days. Among patients who received a triggered PC consult, 43% had no subsequent inpatient or outpatient PC encounter after discharge.

CONCLUSION

Although standardized PC consultation criteria led to earlier PC consultation in older patients with AL, it did not result in sustained PC follow-up throughout the disease trajectory. Future PDSA cycles will focus on identifying strategies to maintain the integration of PC with oncologic care over time, particularly in the ambulatory setting.

Should Outpatient Palliative Care Clinics in Cancer Centers be Stand Alone or Embedded?

Outpatient palliative care facilitates timely symptom management, psychosocial care and care planning. A growing number of cancer centers have either stand-alone or embedded outpatient palliative care clinics. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. One group advocates for stand-alone clinics, another for embedded, and the third group tries to find a balance. In the absence of evidence that directly compares the two models, factors such as cancer center size, palliative care team composition, clinic space availability, and financial considerations may drive the decision-making process at each institution. Stand-alone clinics may be more appropriate for larger academic cancer centers or palliative care programs with a more comprehensive interdisciplinary team, while embedded clinics may be more suited for smaller palliative care programs or community oncology programs to stimulate referrals. As outpatient clinic models continue to evolve, investigators need to document the referral and patient outcomes to inform practice.

Outcomes of a National Training Curriculum to Advance Generalist Level Palliative Care

Background: The adoption of palliative care as an integral component of health care has led to the need for generalist level providers, especially important in serious illnesses such as cancer. Objectives: The goals of this National Cancer Institute-funded training program were to (1) identify the eight domains of quality palliative care applied to oncology practice, (2) demonstrate skills for oncology advanced practice registered nurses (APRNs) in the domains of palliative care, and (3) develop goals for implementing the skills training in practice through process improvement, staff education, and clinical care. Design: The training program led by the End of Life Nursing Education Consortium (ELNEC) project included oncology APRNs in a three-day training course with one-year follow-up for ongoing support and to assess impact. Settings: Five training courses included 430 APRNs from 46 U.S states including both pediatric and adult oncology settings. The project included 25% minority participants. Measurement: Measures included participant goal implementation, course evaluations, and surveys to assess implementation and palliative care practices (precourse, 6 and 12 months postcourse). Results: The ELNEC oncology APRN training course resulted in changes in practice across domains, improved perceived effectiveness in clinical practice, and valuable insight regarding the challenges in generalist level palliative care implementation. Conclusion: The ELNEC oncology APRN course serves as a model for the palliative care field to advance generalist level practice. Future training efforts can build on this project to reach more oncology professionals and those in other areas of serious illness care.

Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review

CONTEXT

Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations.

OBJECTIVES

To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes.

METHODS

We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention.

RESULTS

We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model.

CONCLUSION

Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.

Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: "Care Anywhere, Anytime"

OPINION STATEMENT

The specialty of palliative care has evolved over time to provide symptom management, psychosocial support, and care planning for patients with cancer throughout the disease continuum and in multiple care settings. This review examines the delivery and impact of palliative care in the outpatient, inpatient, and community-based settings. The article will discuss how these 3 palliative care settings can work together to optimize patient outcomes under a unifying model of palliative care "anywhere, anytime" and how to prioritize palliative care services when resources are limited. Many patients with advanced cancer receive care from each of the 3 branches of palliative care-outpatient, inpatient, and community-based settings-at some point along their disease trajectory. Early on, outpatient clinics provide longitudinal supportive care concurrent with active disease-modifying treatments. Telemedicine appointments can serve patients remotely to minimize their need to travel. When patients experience functional decline, community-based palliative care services can provide support and monitoring for patients at home. When patients develop acute symptomatic complications requiring admission, inpatient care consultation teams are essential for symptom management and goals-of-care discussions. For patients in severe distress, receiving care in a palliative care unit that provides intensive symptom control and facilitates complex discharge planning is ideal. Under a unifying model of palliative care designed to offer care "anywhere, anytime," the 3 branches of palliative care could work in unison to support each other, minimize gaps in care, and optimize patient outcomes.

From evidence to practice: early integration of palliative care in a comprehensive cancer center

PURPOSE

The American Society of Clinical Oncology (ASCO) recommends that all patients with a diagnosis of advanced cancer be referred to a palliative care team within 8 weeks of diagnosis. The benefits of early integrated palliative care are well recognized; however, there is a lack of consensus to guide operational aspects of a palliative care service within a comprehensive cancer center. In this study, we explore current palliative care referral patterns at an academic cancer center and provide recommendations for operationalizing palliative care services as a program within comprehensive cancer centers in order to adequately meet the needs of patients with advanced cancer.

METHODS

A retrospective chart review of patients with newly diagnosed metastatic cancer or advanced hematologic malignancy referred to the palliative care team at a comprehensive cancer center from January 1, 2021, to October 31, 2021, was conducted. Institutional Review Board (IRB) approval was obtained prior to the initiation of the chart review.

RESULTS

A total of 243 patients with newly diagnosed metastatic cancer or advanced hematologic malignancy were included in this review. Patients with gastrointestinal (26%), gynecologic (19%), and thoracic (21%) malignancies constituted 66% of the total cohort. The most frequent reason for referral was pain (52%). In total, 39% of patients were referred within 8 weeks of an advanced cancer diagnosis.

CONCLUSION

ASCO recommends that all patients with advanced cancer be referred to a palliative care specialist within 8 weeks of diagnosis. Of the newly referred patients with advanced cancer, only 39% were referred to the palliative care team within 8 weeks of their diagnosis. This considerable gap suggests the need for a consensus with regard to operationalizing the palliative care team.

Situational analysis of the quality of palliative care services across India: a cross-sectional survey

Objective

Palliative care services in India were established in the 1980s but there is no detailed up-to-date knowledge about the quality-of-service provision nationally. We aim to describe the current quality of palliative care provision in India, as measured against nationally adopted standards.

Method

A digital survey adapted from the Indian Association of Palliative Care Standards Audit Tool was administered to 250 palliative care centres.

Results

Two hundred and twenty-three (89%) palliative care centres participated - 26.4% were government-run, while the rest include non-governmental organisations, private hospitals, community-led initiatives and hospices. About 200 centres 'often' or 'always' fulfilled 16/21 desirable criteria; however, only 2/15 essential criteria were 'often' or 'always' fulfilled. Only 5.8% provide uninterrupted access to oral morphine.

Significance of the results

Palliative care centres in India are falling short of meeting the essential quality standards, indicating the urgent need for new initiatives to drive national change.

Early integration of palliative care for patients with haematological malignancies

Early palliative care (EPC) significantly improves quality of life, symptoms, and satisfaction with care for patients with advanced cancer. International organizations have recognized and promoted the role of palliative care as a distinct specialty, advocating its involvement throughout the cancer trajectory. Although patients with haematologic malignancies (HMs) have a comparable symptom burden to patients with solid tumours, they face multiple barriers to EPC integration. In this review, we discuss these barriers, present updated evidence from clinical trials of EPC in HMs and propose models to support EPC integration into care for patients with HMs.

Beyond 9 to 5: Expansion of an Inpatient Specialist Palliative Care Service to 24/7 Onsite Presence

For seriously ill hospitalized patients with a diagnosis of cancer, there exists a need for specialist palliative care, 24 hours a day, 7 days a week. This article describes the expansion of a palliative care consult service in a metropolitan, dedicated cancer hospital to provide 24/7 specialist palliative care including onsite overnight presence by advanced practice registered nurses and to evaluate the impact of this change on nighttime utilization of the consult service. Inpatient management encounters and outpatient calls were compared before and after the expansion. The onsite availability of a palliative care specialist between midnight and 8 am increased from less than 10% of the time in 2019 to 100% of the time in 2021. The number of inpatient overnight calls and pages increased from a median of 4 to 16, and the number of follow-up visits evaluated increased from a median of 0 to 6. However, the number of overnight palliative care consults and outpatient calls evaluated did not change significantly. Expansion of a hospital-based palliative care service to include 24/7 onsite overnight presence increased patient, family, and night staff access to high-quality palliative care, prompt symptom management, and staff coaching on primary palliative care skills.

Multidisciplinary Clinician Perspectives on Embedded Palliative Care Models in Pediatric Cancer

CONTEXT

Integration of palliative care (PC) into pediatric cancer care is considered best practice by national oncology and pediatric organizations. Optimal strategies for PC integration remain understudied, although growing evidence suggests that embedded models improve quality of care and quality of life for patients and families.

OBJECTIVES

To describe the perspectives and preferences of multidisciplinary clinicians regarding ideal models for PC integration in pediatric cancer care; to introduce clinicians to the theoretical concept of an embedded care model; to empower clinicians in co-design of a new institutional model through collaborative discussion of anticipated benefits and challenges of embedded model implementation.

METHODS

Trained facilitators conducted 24 focus groups, stratified by discipline and care team. Focus groups were audio-recorded and transcribed for inductive content analysis using MAXQDA software.

RESULTS

174 clinicians participated (25 physicians, 30 advanced practice providers [APPs], 70 nurses, 49 psychosocial clinicians). Clinicians across disciplines verbalized that an embedded PC model would improve access to PC; however, identified benefits and challenges varied by discipline. Benefits included earlier integration of PC (physicians, APPs), normalization of PC as an integral aspect of care by patients/families (nurses, psychosocial), collaboration (physicians, psychosocial clinicians), and communication (APPs, psychosocial). Anticipated challenges included inadequate resources and physician resistance (physicians, APPs, nurses) and multidisciplinary role confusion (APPs, nurses, psychosocial).

CONCLUSION

Pediatric clinicians recognize the potential value of an embedded PC model. Although some concepts overlapped, multidisciplinary clinicians offered unique beliefs, highlighting the importance of including representative perspectives to ensure that pediatric PC models align with priorities of diverse stakeholders.

Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician

Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.

Trends and outcomes of early and late palliative care consultation for adult patients with glioblastoma: A SEER-Medicare retrospective study

Background

Glioblastoma (GBM) carries a poor prognosis despite standard of care. Early palliative care (PC) has been shown to enhance survival and quality of life while reducing healthcare costs for other cancers. This study investigates differences in PC timing on outcomes for patients with GBM.

Methods

This study used Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1997 to 2016. Based on ICD codes, three groups were defined: (1) early PC within 10 weeks of diagnosis, (2) late PC, and (3) no PC. Outcomes were compared between the three groups.

Results

Out of 10 812 patients with GBM, 1648 (15.24%) patients had PC consultation with an overall positive trend over time. There were no significant differences in patient characteristics. The late PC group had significantly higher number of hospice claims (1.06 ± 0.69) compared to those without PC, in the last month of life. There were significant differences in survival among the three groups (P < .0001), with late PC patients with the longest mean time to death from diagnosis (11.72 ± 13.20 months).

Conclusion

We present the first investigation of PC consultation prevalence and outcomes, stratified by early versus late timing, for adult GBM patients. Despite an overall increase in PC consultations, only a minority of GBM patients receive PC. Patients with late PC had the longest survival times and had greater hospice use in the last month of life compared to other subgroups. Prospective studies can provide additional valuable information about this unique population of patients with GBM.

Development of a national health policy logic model to accelerate the integration of oncology and palliative care: a nationwide Delphi survey in Japan

BACKGROUND

Despite recommendations to deliver palliative care to cancer patients and their caregivers, their distress has not been alleviated satisfactorily. National health policies play a pivotal role in achieving a comprehensive range of quality palliative care delivery for the public. However, there is no standardised logic model to appraise the efficacy of these policies. This study aimed to develop a logic model of a national health policy to deliver cancer palliative care and to reach consensus towards specific policy proposals.

METHODS

A draft version of the logic model and specific policy proposals were formulated by the research team and the internal expert panel, and the independent external expert panel evaluated the policy proposals based on the Delphi survey to reach consensus.

RESULTS

The logic model was divided into three major conceptual categories: 'care-delivery at cancer hospitals', 'community care coordination', and 'social awareness of palliative care'. There were 18 and 45 major and minor policy proposals, which were categorised into four groups: requirement of government-designated cancer hospitals; financial support; Basic Plan to Promote Cancer Control Programs; and others. These policy proposals were independently evaluated by 64 external experts and the first to third Delphi round response rates were 96.9-98.4%. Finally, 47 policy proposals reached consensus. The priority of each proposal was evaluated within the four policy groups.

CONCLUSIONS

A national health policy logic model was developed to accelerate the provision of cancer palliative care. Further research is warranted to verify the study design to investigate the efficacy of the logic model.

Is treatment in certified cancer centers related to better survival in patients with pancreatic cancer? Evidence from a large German cohort study

BACKGROUND

Treatment of cancer patients in certified cancer centers, that meet specific quality standards in term of structures and procedures of medical care, is a national treatment goal in Germany. However, convincing evidence that treatment in certified cancer centers is associated with better outcomes in patients with pancreatic cancer is still missing.

METHODS

We used patient-specific information (demographic characteristics, diagnoses, treatments) from German statutory health insurance data covering the period 2009-2017 and hospital characteristics from the German Standardized Quality Reports. We investigated differences in survival between patients treated in hospitals with and without pancreatic cancer center certification by the German Cancer Society (GCS) using the Kaplan-Meier estimator and Cox regression with shared frailty.

RESULTS

The final sample included 45,318 patients with pancreatic cancer treated in 1,051 hospitals (96 GCS-certified, 955 not GCS-certified). 5,426 (12.0%) of the patients were treated in GCS-certified pancreatic cancer centers. Patients treated in certified and non-certified hospitals had similar distributions of age, sex, and comorbidities. Median survival was 8.0 months in GCS-certified pancreatic cancer centers and 4.4 months in non-certified hospitals. Cox regression adjusting for multiple patient and hospital characteristics yielded a significantly lower hazard of long-term, all-cause mortality in patients treated in GCS-certified pancreatic centers (Hazard ratio = 0.89; 95%-CI = 0.85-0.93). This result remained robust in multiple sensitivity analyses, including stratified estimations for subgroups of patients and hospitals.

CONCLUSION

This robust observational evidence suggests that patients with pancreatic cancer benefit from treatment in a certified cancer center in terms of survival. Therefore, the certification of hospitals appears to be a powerful strategy to improve patient outcomes in pancreatic cancer care.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04334239 ).

Different Associations Between Inpatient or Outpatient Palliative Care and End-of-Life Outcomes for Hospitalized Patients With Cancer

PURPOSE

Palliative care (PC) improves outcomes in advanced cancer, and guidelines recommend early outpatient referral. However, many PC teams see more inpatient than outpatient consults. We conducted a retrospective study of hospitalized patients with cancer to quantify exposure to inpatient and outpatient PC and describe associations between PC and end-of-life (EOL) quality measures.

METHODS

We identified all decedents admitted to an inpatient oncology unit in 1 year (October 1, 2017-September 30, 2018) and abstracted hospitalization statistics, inpatient and outpatient PC visits, and EOL outcomes. Descriptive statistics, univariate tests, and multivariate analysis evaluated associations between PC and patient outcomes.

RESULTS

In total, 522 decedents were identified. 50% saw PC; only 21% had an outpatient PC visit. Decedents seen by PC were more likely to enroll in hospice (78% v 44%; P < .001), have do-not-resuscitate status (87% v 55%; P < .001), have advance care planning documents (53% v 31%; P < .001), and die at home or inpatient hospice instead of in hospital (67% v 40%; P < .01). Decedents seen by PC had longer hospital length-of-stay (LOS; 8.4 v 7.0 days; P = .03), but this association reversed for decedents seen by outpatient PC (6.3 v 8.3 days; P < .001), who also had longer hospice LOS (46.5 v 27.1 days; P < .01) and less EOL intensive care (6% v 15%; P < .05).

CONCLUSION

PC was associated with significantly more hospice utilization and advance care planning. Patients seen specifically by outpatient PC had shorter hospital LOS and longer hospice LOS. These findings suggest different effects of inpatient and outpatient PC, underscoring the importance of robust outpatient PC.

Impact of an Embedded Palliative Care Clinic on Healthcare Utilization for Patients With a New Thoracic Malignancy

Introduction

Palliative care is beneficial for patients with advanced lung cancer, but the optimal model of palliative care delivery is unknown. We investigated healthcare utilization before and after embedding a palliative care physician within a thoracic medical oncology "onco-pall" clinic.

Methods

This is a retrospective cross-sectional cohort study comparing healthcare outcomes in two cohorts: "pre-cohort" 12 months prior to and "post-cohort" 12-months after the onco-pall clinic start date. Patients were included if they had a new diagnosis of lung cancer and received care at The Ohio State University Thoracic Oncology Center, and resided in Franklin County or 6 adjacent counties. During the pre-cohort time period, access to palliative care was available at a stand-alone palliative care clinic. Palliative care intervention in both cohorts included symptom assessment and management, advance care planning, and goals of care discussion as appropriate. Outcomes evaluated included rates of emergency department (ED) visits, hospital admissions, 30-day readmissions, and intensive care unit (ICU) admissions. Estimates were calculated in rates per-person-years and with Poisson regression models.

Results

In total, 474 patients met criteria for analysis (214 patients included in the pre-cohort and 260 patients in the post-cohort). Among all patients, 52% were male and 48% were female with a median age of 65 years (range 31-92). Most patients had non-small cell lung cancer (NSCLC - 17% stage 1-2, 20% stage 3, 47% stage 4) and 16% had small cell lung cancer. The post-cohort was older [median age 66 years vs 63 years in the pre-cohort (p-value: < 0.01)]. The post-cohort had a 26% reduction in ED visits compared to the pre-cohort, controlling for age, race, marital status, sex, county, Charlson score at baseline, cancer type and stage (adjusted relative risk: aRR: 0.74, 95% CI: 0.58-0.94, p-value = 0.01). Although not statistically significant, there was a 29% decrease in ICU admissions (aRR: 0.71, 95% CI: 0.41-1.21, p-value = 0.21) and a 15% decrease in hospital admissions (aRR: 0.85, 95% CI: 0.70-1.03, p-value = 0.10). There was no difference in 30-day readmissions (aRR: 1.03, 95% CI: 0.73-1.45, p-value = 0.85).

Conclusions

Embedding palliative care clinics within medical oncology clinics may decrease healthcare utilization for patients with thoracic malignancies. Further evaluation of this model is warranted.

Timely Palliative Care: Personalizing the Process of Referral

Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.