End-of-life decisions guiding the palliative care of cancer patients visiting emergency department in South Western Finland: a retrospective cohort study

The effect of palliative outpatient units on resource use for cancer patients in Finland

BACKGROUND

As cancer incidences are increasing, the means to provide effective palliative care (PC) are called for. There is evidence, that PC may prevent futile treatment at the end of life (EOL) thus implicating that PC decreases resource use at the EOL, however, the effects of outpatient PC units remain largely unknown. We surveyed the national use of Finnish tertiary care PC units and their effects on resource use at the EOL in real-life environments.

PATIENTS AND METHODS

Cancer patients treated in the departments of Oncology at all five Finnish university hospitals in 2013 and deceased by 31 December 2014 were identified; of the 6010 patients 2007 were randomly selected for the study cohort. The oncologic therapies received and the resource usage of emergency services and hospital wards were collected from the hospitals' medical records.

RESULTS

A PC unit was visited by 37% of the patients a median 112 days before death. A decision to terminate all life-prolonging cancer treatments was more often made for patients visiting the PC unit (90% vs. 66%, respectively). A visit to a PC unit was associated with significantly fewer visits to emergency departments (ED) and hospitalization during the last 90 days of life; the mean difference in ED visits decreased by 0.48 (SD 0.33 - 0.62, p < 0.001), and the mean inpatient days by 7.1 (SD 5.93 - 8.25, p < 0.001). A PC visit unit was independently associated with decreased acute hospital resource use during the last 30 and 90 days before death in multivariable analyses.

CONCLUSION

Cancer patients' contact with a PC unit was significantly associated with the reduced use of acute hospital services at the EOL, however; only one-third of the patients visited a PC unit. Thus, systematic PC unit referral practices for patients with advanced cancer are called for.

Effect of palliative care decisions making on hospital service use at end-of-life in patients with malignant brain tumors: a retrospective study

BACKGROUND

Palliative care (PC) improves Quality of life and reduces the symptom burden. Aggressive treatments at end of life (EOL) postpone PC. The aim of this single-center retrospective study was to evaluate the timing of the PC decision i.e., termination of cancer-specific treatments and focusing on symptom-centered PC, and its impact on the use of tertiary hospital services at the EOL.

METHODS

A retrospective cohort study on brain tumor patients, who were treated at the Comprehensive Cancer Center of the Helsinki University Hospital from November 1993 to December 2014 and died between January 2013 and December 2014, were retrospectively reviewed. The analysis comprised 121 patients (76 glioblastoma multiforme, 74 males; mean age 62 years; range 26-89). The decision for PC, emergency department (ED) visits and hospitalizations were collected from hospital records.

RESULTS

The PC decision was made for 78% of the patients. The median survival after diagnosis was 16 months (13 months patients with glioblastoma), and after the PC decision, it was 44 days (range 1-293). 31% of the patients received anticancer treatments within 30 days and 17% within the last 14 day before death. 22% of the patients visited an ED, and 17% were hospitalized during the last 30 days of life. Of the patients who had a PC decision made more than 30 days prior to death, only 4% visited an ED or were hospitalized in a tertiary hospital in the last 30 days of life compared to patients with a late (< 30 days prior to death) or no PC decision (25 patients, 36%).

CONCLUSIONS

Every third patient with malignant brain tumors had anticancer treatments during the last month of life with a significant number of ED visits and hospitalizations. Postponing the PC decision to the last month of life increases the risk of tertiary hospital resource use at EOL.

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

BACKGROUND

Existing evidence suggest the emergence of palliative care (PC) services in the emergency department (ED). To gain insight into the nature of these services and provide direction to future actions, there is a need for a comprehensive review that ascertains the components of these services, integration models, and outcomes.

METHODS

A scoping review design was employed and reported according to the PRISMA extension guidelines for scoping reviews. Extensive searches in peer-reviewed databases (CINAHL, EMBASE, PubMed, Cochrane Library, and Medline) and gray literature sources (Trove, MedNar, OpenGrey, and the Agency for Healthcare Research and Quality) were undertaken and supplemented with hand searching. Titles, abstracts, and full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on a PC intervention implemented in the ED for adults. Codes were formulated across the included studies, which facilitated the conduct of a narrative synthesis.

RESULTS

Twenty-three studies were retained with the majority (n = 15) emerging from the United States. The components of PC interventions in the ED were categorized as: (1) screening, (2) goals of care discussion and communication, (3) managing pain and other distressing symptoms in the ED, (4) transitions across care settings, (5) end-of-life (EoL) care, (6) family/caregiver support, and (7) ED staff education. Traditional PC consultations and integrated ED-PC services were the main modes of delivery. PC in the ED can potentially improve patient symptoms, facilitate access to relevant services, reduce length of stay, improve care at the EoL, facilitate bereavement and postbereavement support for family members, and improve ED staff confidence in delivering PC.

CONCLUSIONS

PC implementation in the ED may potentially improve patient and family outcomes. More studies are needed, however, to standardize trigger or screening tools. More prospective studies are also needed to test PC interventions in the ED.

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand

Background

The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality.

Methods

A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included.

Results

A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was ‘cannot control symptoms’ (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality.

Conclusion

The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01009-z.

Trends in end-of-life decisions among patients dying in a university hospital oncology ward after implantation of a palliative outpatient clinic

BACKGROUND

The need for high quality palliative care at end-of-life has been increasingly recognized while regional differences exist in its quality and availability. Basic palliative care is given by oncologists at any stage of the disease, but this does not cover the high need for specialized palliative care. The aim of this study was to assess the trends in end-of-life decisions among patients dying in a university hospital oncology ward before and after the implementation of a palliative outpatient clinic.

MATERIAL AND METHODS

The study population consists of all patients who died in the Kuopio University Hospital oncology ward between 1.1.2010-31.10.2011 and 1.1.2012-31.12.2018. The palliative outpatient clinic was established and set up in November - December 2011. Data on inpatient stays, cancer treatments, treatment decisions, and some background factors were retrieved from electronic records.

RESULTS

The study population totaled 644 patients dying in the oncology ward at KUH (57.8% males; 42.2% females). The deaths comprise 17.2% (191/1108) of all cancer deaths in 2010-2011 and 11.1% (461/4049) in 2012-2018 in the KUH catchment area (North-Savo Health Care District). In years 2012-2018, 14.1% of patients treated at KUH oncology clinic visited the palliative outpatient clinic. The percentage of DNR (do-not-resuscitate), palliative care, and end-of-life (EOL) care decisions increased significantly in the later period. The decisions were mainly made during the last week of life. The proportion of patients receiving chemotherapy during the last two weeks of life remained stable.

CONCLUSION

The proportion of patients receiving DNR, palliative care and EOL care decisions increased after the implementation of the palliative outpatient clinic, but the decisions were still made rather late, mainly during the last days of life.

Accessibility of information on patients' and family members' end-of-life wishes in advance care planning

AIM

To describe healthcare professionals' accessibility and transfer of patients' and family members' end-of-life wishes in ACP to the palliative care unit.

DESIGN

The study used a qualitative descriptive study design.

METHODS

Purposive sampling was used. The data (N = 33) were collected through interviews with physicians, registered nurses, practical nurses and social workers. The data were analysed by inductive content analysis.

RESULTS

Two main categories emerged. Patients' and family members' end-of-life wishes documentation in relation to changing information needs was described in relation to patients' condition and care context. Transfer of patients' and family members' end-of-life wishes to palliative care unit included written and verbal communication. Results showed lack of implementation of ACP early, lack of implementation about the holistic interpretation of ACP into medical notes and lack of transferability of ACP into documenting systems impacting on accessibility and realization for the patient and family members at the end-of-life.

Terms used by physicians when deciding to withhold treatment for older patients not having received palliative care in an acute geriatric care unit

PURPOSE

There are no guidelines or consensus statements on the terms to be used when discussing withholding of treatment for patients in acute geriatric care units and who have not received palliative care. The objective of the present study was to analyze the terms used in medical records to refer to the withholding of treatment for patients who died in an acute geriatric care unit and did not receive palliative care.

METHODS

We conducted an ambispective multicentre cohort study based on the DAMAGE study. Data on 53 patients who died in the acute geriatric care unit and who had not received palliative care were extracted from medical records. The verbatims referring to the withholding of treatment were analyzed in terms of keywords and then key concepts, as defined by several reviewers in a consensus-based approach.

RESULTS

The mean age of the patients was 86.4 years, 34.1% were male. Terms referring to the withholding of treatment were found for 25 of the 53 patients (47.2%). Most of the decisions on the withholding of treatment were recorded in the week following admission to the acute geriatric care unit. Our analysis of the terms identified 11 key concepts: treatment limitation, no resuscitation, withholding diagnostic procedures, justification of care, ethical considerations, disease progression, uncertainty, the patient's wishes, the family's wishes, patient's comfort, and collegiality. The terms used to describe key concepts varied markedly from one physician to another.

CONCLUSION

Decisions about the withholding of treatment are frequently noted in the medical records of patients who die in the acute geriatric care unit without having received palliative care. The broad variety of key concepts and differences in the choice of words highlight the need for standardized terms.

Emergency Department Use by Terminally Ill Patients: A Systematic Review

CONTEXT

Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear.

OBJECTIVE

To determine the prevalence of TIP visiting the ED.

METHODS

Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle-Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I²).

RESULTS

We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37-54%] and 75% in the last six months of life [95% CI 62-83%]; I² = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12-23%]; I² = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping.

CONCLUSIONS

Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.

End-of-life care among patients with pancreatic cancer with or without palliative intervention: a retrospective single-centre study

INTRODUCTION

Palliative care can reduce the symptom burden and may increase the life expectancy for patients with advanced malignancies. The aim of this study was to evaluate the impact of palliative intervention on the treatment procedures for pancreatic cancer patients during their last month of life.

MATERIAL AND METHODS

This retrospective single-centre study included adult pancreatic cancer patients who were treated in Turku University Hospital during their last month of life and died between 2011 and 2016. Data were collected from hospital database. Oncological treatments, the number of radiological examinations and procedures, surgical procedures, emergency department visits, hospitalisations, the place of death and medical costs were examined in tertiary care for patients with or without contact to the palliative care unit.

RESULTS

From 378 eligible patients, 20% (n = 76) had a contact to the palliative care unit. These patients had less radiological examinations (p < 0.0001), hospitalisations (p <0.0001) and emergency department visits (p = 0.021) during the last month of life. They did not die in the university hospital as often (p = 0.011) and median of their medical costs during the last month of life was approximately half (p <0.0001) when compared to patients with no palliative intervention (n = 302). They had longer overall survival (p <0.0001) which was the only difference detected in the characteristics of the groups.

CONCLUSION

Fewer treatment procedures and lower tertiary care costs during the last month of life were observed for the pancreatic cancer patients who had a contact to the palliative care unit. Palliative care intervention should be an essential part of the treatment schedule for these patients.

The impact of the duration of the palliative care period on cancer patients with regard to the use of hospital services and the place of death: a retrospective cohort study

Background

In order to avoid unnecessary use of hospital services at the end-of-life, palliative care should be initiated early enough in order to have sufficient time to initiate and carry out good quality advance care planning (ACP). This single center study assesses the impact of the PC decision and its timing on the use of hospital services at EOL and the place of death.

Methods

A randomly chosen cohort of 992 cancer patients treated in a tertiary hospital between Jan 2013 –Dec 2014, who were deceased by the end of 2014, were selected from the total number of 2737 identified from the hospital database. The PC decision (the decision to terminate life-prolonging anticancer treatments and focus on symptom centered palliative care) and use of PC unit services were studied in relation to emergency department (ED) visits, hospital inpatient days and place of death.

Results

A PC decision was defined for 82% of the patients and 37% visited a PC unit. The earlier the PC decision was made, the more often patients had an appointment at the PC unit (> 180 days prior to death 72% and < 14 days 10%). The number of ED visits and inpatient days were highest for patients with no PC decision and lowest for patients with both a PC decision and an PC unit appointment (60 days before death ED visits 1.3 vs 0.8 and inpatient days 9.9 vs 2.9 respectively, p < 0.01). Patients with no PC decision died more often in secondary/tertiary hospitals (28% vs. 19% with a PC decision, and 6% with a decision and an appointment to a PC unit).

Conclusions

The PC decision to initiate a palliative goal for the treatment had a distinct impact on the use of hospital services at the EOL. Contact with a PC unit further increased the likelihood of EOL care at primary care.

Advance care planning for patients with cancer in palliative care: A scoping review from a professional perspective

AIMS AND OBJECTIVES

To describe advance care planning (ACP) for patients with cancer in palliative care from professionals' perspective.

BACKGROUND

The number of patients with cancer is increasing. Palliative care should be based on timely ACP so that patients receive the care they prefer.

DESIGN

A scoping review.

METHODS

A systematic literature search was conducted in January 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used. The methodological quality of the studies was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal tools. Data were analysed with content analysis.

RESULTS

Of 739 studies identified, 12 were eligible for inclusion. The settings were inpatient and outpatient facilities in special and primary care including oncology, palliative and hospice care. ACP consisted of patient-oriented issues, current and future treatment, and end-of-life matters. The participants were nursing, medical or social professionals. ACP conversations rarely occurred; if they did, they took place at the onset, throughout and late in the cancer.

CONCLUSIONS

Professionals could not separate day-to-day care planning and ACP. ACP documentation was scattered and difficult to find and use. Professionals were unfamiliar with ACP, and established practices were lacking. ACP conversations mostly occurred in late cancer. Further research clarifying concepts and exploring the significance of ACP for patients and relatives is recommended.

RELEVANCE TO CLINICAL PRACTICE

Our results support the use of ACP by a multidisciplinary team from the early stages of cancer as a discussion forum around patients' wishes and choices. We showed the need to raise professionals' awareness of ACP. Education and appropriate data tools for ACP are important as they may reduce reluctance and promote ACP use. This paper contributes to the wider global clinical community by pointing out the importance of standardising ACP contents and practices.

Assessing the utilization of the decision to implement a palliative goal for the treatment of cancer patients during the last year of life at Helsinki University Hospital: a historic cohort study

Background: To avoid aggressive treatments at the end-of-life and to provide palliative care (PC), physicians need to terminate futile anti-cancer treatments and define the palliative goal of the treatment in time. This single center study assesses the practices used to make the decision that leads to treatment with a palliative goal, i.e., the PC decision and its effect on anti-cancer treatments at the end of life.Material and methods: Patients with a cancer diagnosis treated in tertiary hospital during 1st January 2013 - 31st December 2014 and deceased by the end of 2014 were identified in the hospital database (N = 2737). Of these patients, 992 were randomly selected for this study. The PC decision was screened from patient records, i.e., termination of cancer-specific treatments and a focus on symptom-centered PC.Results: The PC decision was defined in 82% of the patients during the last year of life (49% >30 days and 33% ≤30 days before death, 18% with no decision). The median time from the decision to death was 46 days. Systemic cancer therapy was given during the last month of life in 1%, 36% and 38% (p < .001) and radiotherapy 22%, 40% and 31% (p = .03) cases, respectively; referral to a PC unit was made in 62%, 22% and 11%, respectively (p < .001). In logistic regression analyses younger age, shorter duration of the disease trajectory and type of cancer (e.g., breast cancer) were associated with a lack or late timing of the PC decision.Conclusion: The decision to initiate a palliative goal for the treatment was frequently made for cancer patients but occurred late for every third patient. Younger age and certain cancer types were associated with late PC decisions, thus leading to anti-cancer treatments continuing until close to the death with low access to a PC unit.

Barriers to the composition and implementation of advance directives in oncology: a literature review

The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.