Access to palliative care among patients treated at a comprehensive cancer center

Fatality from COVID-19 does not affect palliative care duration among patients with advanced cancer: a retrospective cohort study

BACKGROUND

Jomar et al. demonstrated that death due to COVID-19 did not affect the time under exclusive palliative care among patients with advanced cancer, even during the first year of the pandemic caused by a hitherto little-known disease.

BACKGROUND

◼ Fatality due to COVID-19 does not alter the time under oncological palliative care.

BACKGROUND

◼ The retrospective design of this pioneering study allows causal inference.

BACKGROUND

◼ Access to oncological palliative care frequently approaches terminality of life.

OBJECTIVE

This study aimed at investigating the extent to which COVID-19-induced fatalities affect the duration of palliative care among patients with advanced cancer.

METHODS

A retrospective cohort study was conducted at the Palliative Care Unit of the Brazilian Instituto Nacional de Câncer in Rio de Janeiro, Brazil, on 1,104 advanced cancer patients who died under exclusive palliative care between March 11, 2020, and March 31, 2021. Wilcoxon rank-sum (Mann-Whitney U) and log-rank tests were performed to examine statistical differences between the medians of time, and the Kaplan-Meier estimator was used to graphically illustrate survival over time under exclusive palliative care contingent upon the underlying causes of death of the two experimental groups (cancer versus COVID-19).

RESULTS

A total of 133 (12.05%) patients succumbed to COVID-19. In both groups, the median time under exclusive palliative care was less than one month. The exclusive palliative care survival curves did not exhibit any statistically significant difference between the groups.

CONCLUSION

Death due to COVID-19 did not modify the duration of exclusive palliative care among patients with advanced cancer.

Integrating palliative care into multiple myeloma management : Optimizing quality of life across the disease continuum

BACKGROUND

Multiple myeloma (MM) poses significant challenges due to its complex symptomatology and evolving treatment landscape. While therapeutic advances have improved survival outcomes, holistic management of MM requires addressing the numerous physical and psychosocial needs of patients. Palliative care (PC) offers a comprehensive approach to symptom management and supportive care on a physical, psychosocial and spiritual level; however, its role in MM remains underexplored.

METHODS

This retrospective single-center study examines the outcome of 22 MM patients admitted to the Division of Palliative Medicine at the Medical University of Vienna. We investigated reasons for admission, symptom severity, functional status, length of stay and overall survival.

RESULTS

Most common reasons for palliative care unit (PCU) admission were nutritional problems (82%), fatigue (77%) and pain (68%). Median ECOG score at PCU admission was 3. The timepoint within the timeline of myeloma disease at which hospitalization took place varied greatly. Some patients were hospitalized shortly after diagnosis, other patients after many years of active disease and therapy. Median time from MM initial diagnosis to first PCU stay was 4.3 years (range 0.6-23.8 years). The median length of hospital (PCU) stay was 11 days (range 1-127days) and 45% of patients died during PCU hospitalization. The reduction in symptom burden as a result of the inpatient stay in the PCU is reflected in the PERS2ON score, which was measured on the day of admission (median 23 days, range 6-32 days) and on the day of discharge (median 16 days, range 7-20 days).

CONCLUSION

PC interventions effectively addressed the complex symptom burden experienced by patients with MM. Multidimensional approaches encompassing physical, psychological and social domains proved instrumental in optimizing quality of life. Integrating PC principles into MM management paradigms is essential to prioritize patient-centered care across the disease continuum.

Differences in Patient-Reported Outcome Measures in Patients With Cancer Six Months Before Death

PURPOSE

Patient-reported outcome measures (PROMs) provide a direct report of the patient's perspective, complementary to clinician assessment. Currently, understanding the real-time changes in PROM scores near the end of life remains limited. This study evaluated differences in mean PROM scores between patients with cancer within 6 months before death compared with surviving patients with cancer.

METHODS

This retrospective case-control study uses the National Institutes of Health's Patient-Reported Outcomes Measurement Information System computer adaptive testing instruments to assess pain interference, physical function, fatigue, and depression. Patients dying within 6 months of PROM completion were selected as cases and matched to controls 1:3 by age at PROM completion, sex, cancer disease site, and cancer stage at diagnosis. Generalized estimating equation models assessed the difference in mean PROM score in cases compared with controls.

RESULTS

A total of 461 cases and 1,270 controls from September 2020 to January 2023 were included. After adjustment for ethnicity, Charlson Comorbidity Index, and census tract median household income, significant differences in mean scores were demonstrated. Physical function domain showed the largest difference, with cases averaging 6.52 points lower than controls (95% CI, -8.25 to -4.80). Fatigue and pain interference domains showed a rise in PROMs scores by 4.83 points (95% CI, 2.94 to 6.72) and 4.33 points (95% CI, 2.53 to 6.12), respectively.

CONCLUSION

Compared with controls, patients dying within 6 months of PROM completion demonstrated worse PROM scores in the four domains assessed. These findings suggest the utility of routinely collected PROMs as a real-time indicator of the terminal stage of life among patients with cancer to allow for earlier intervention with supportive oncology services.

Patient Experiences of Specialty Palliative Care in the Perioperative Period for Cancer Surgery

CONTEXT

Though patients undergoing treatment for upper gastrointestinal (GI) cancers frequently experience a range of sequelae and disease recurrence, patients often do not receive specialty palliative care soon after diagnosis and it is unknown in what ways they may benefit.

OBJECTIVES

To understand patient experiences of specialty palliative care in the perioperative period for patients seeking curative intent upper GI oncologic surgery.

METHODS

As part of a randomized controlled trial, we conducted in-depth interviews between November 2019 and July 2021 with 23 patients in the intervention arm who were undergoing curative intent treatment for upper GI cancers and who were also followed by the specialty palliative care team.

RESULTS

We found five themes that characterized patient experiences and perceptions of specialty palliative care. Patients typically had limited prior awareness of palliative care (theme 1), but during the study, came to understand it as a "talking" intervention (theme 2). Patients whose concerns aligned with palliative care described it as being impactful on their care (theme 3). However, most patients expressed a focus on cure from their cancer and less perceived relevance for integration of palliative care (theme 4). Integrating specialist palliative care practitioners with surgical teams made it difficult for some patients to identify how palliative care practitioners differed from other members of their care team (theme 5).

CONCLUSION

While receipt of specialty palliative care in the perioperative period was generally perceived positively and patients appreciated palliative care visits, they did not describe many needs typically met by palliative care practitioners.

TRIAL REGISTRATION

clinicaltrials.gov registration: NCT03611309.

Enhancing end-of-life care quality and achieving a good death for the elderly in Japan

BACKGROUND

In the context of an aging populations, there is an escalating need for palliative care tailored to the needs of the elderly. This study aimed to assess differences in symptoms and good death among the elderly, along with the structures and processes involved in end-of life care, and to explore the impact of age on achieving a good death.

METHODS

We conducted a questionnaire survey for bereaved family members of patients with cancer, heart disease, stroke, pneumonia, and kidney failure in 2019 and 2020. The study population was categorized into the following age groups: ≤64, 65-74, 75-84, and ≥85. The outcomes included symptom intensity, achievement of a good death, and receipt of quality care.

RESULTS

In total, 62,576 bereaved family members agreed to participate in the survey (response rate; 54.0 %). The weighted percentages of 'severe' and 'very severe' symptoms decreased with age. These trends were observed across age groups, even among the elderly. The strongest effect of age on achieving a good death was found for 'feeling that life is complete' with reference to those aged ≤64 years: 65-74 years (odds ratio [OR]; 2.09, 95 % CI; 1.94 to 2.25), 75-84 years (OR; 4.86, 95 % CI; 4.52 to 5.22) and ≥85 years (OR; 12.8, 95 % CI; 11.9 to 13.8).

CONCLUSION

Age-specific differences were observed in quality of death, quality of care, and symptom intensity. It is important to provide individualized consideration for each age group rather than categorizing them broadly as the elderly when caring for them.

Stepped Palliative Care for Patients With Advanced Lung Cancer: A Randomized Clinical Trial

Importance

Despite the evidence for early palliative care improving outcomes, it has not been widely implemented in part due to palliative care workforce limitations.

Objective

To evaluate a stepped-care model to deliver less resource-intensive and more patient-centered palliative care for patients with advanced cancer.

Design, Setting, and Participants

Randomized, nonblinded, noninferiority trial of stepped vs early palliative care conducted between February 12, 2018, and December 15, 2022, at 3 academic medical centers in Boston, Massachusetts, Philadelphia, Pennsylvania, and Durham, North Carolina, among 507 patients who had been diagnosed with advanced lung cancer within the past 12 weeks.

Intervention

Step 1 of the intervention was an initial palliative care visit within 4 weeks of enrollment and subsequent visits only at the time of a change in cancer treatment or after a hospitalization. During step 1, patients completed a measure of quality of life (QOL; Functional Assessment of Cancer Therapy-Lung [FACT-L]; range, 0-136, with higher scores indicating better QOL) every 6 weeks, and those with a 10-point or greater decrease from baseline were stepped up to meet with the palliative care clinician every 4 weeks (intervention step 2). Patients assigned to early palliative care had palliative care visits every 4 weeks after enrollment.

Main Outcomes and Measures

Noninferiority (margin = -4.5) of the effect of stepped vs early palliative care on patient-reported QOL on the FACT-L at week 24.

Results

The sample (n = 507) mostly included patients with advanced non-small cell lung cancer (78.3%; mean age, 66.5 years; 51.4% female; 84.6% White). The mean number of palliative care visits by week 24 was 2.4 for stepped palliative care and 4.7 for early palliative care (adjusted mean difference, -2.3; P < .001). FACT-L scores at week 24 for the stepped palliative care group were noninferior to scores among those receiving early palliative care (adjusted FACT-L mean score, 100.6 vs 97.8, respectively; difference, 2.9; lower 1-sided 95% confidence limit, -0.1; P < .001 for noninferiority). Although the rate of end-of-life care communication was also noninferior between groups, noninferiority was not demonstrated for days in hospice (adjusted mean, 19.5 with stepped palliative care vs 34.6 with early palliative care; P = .91).

Conclusions and Relevance

A stepped-care model, with palliative care visits occurring only at key points in patients' cancer trajectories and using a decrement in QOL to trigger more intensive palliative care exposure, resulted in fewer palliative care visits without diminishing the benefits for patients' QOL. While stepped palliative care was associated with fewer days in hospice, it is a more scalable way to deliver early palliative care to enhance patient-reported outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03337399.

Intensity of Symptoms and Perception of Quality of Life on Admission to Palliative Care: Reality of a Portuguese Team

BACKGROUND

Palliative care (PC) corresponds to an approach that enhances the quality of life for patients facing life-threatening diseases, such as cancer, as well as for their families. There are various models for providing palliative care. Early referral to PC of patients with advanced cancer has a significant positive impact on their quality of life. However, the criteria for early referral still remain controversial.

OBJECTIVES

To evaluate patients' symptomatic intensity and perception of quality of life on admission to a PC unit and to analyze these two variables according to different models of approach (outpatient and inpatient care).

METHODS

A cross-sectional, descriptive, and correlational study was conducted with a sample of 60 patients sequentially admitted to a PC unit from palliative outpatient consultations or other inpatient services in a tertiary hospital dedicated to oncology care. The evaluation protocol included a sociodemographic and medical questionnaire, the Edmonton Symptom Assessment Scale (ESAS), and the Palliative Care Outcome Scale (POS) completed by patients within the first 24 h after admission.

RESULTS

The participants were mostly male (61.7%), with a median age of 72 years. The majority of patients (n = 32; 53.3%) were undergoing outpatient treatment, while the remaining individuals (n = 28; 46.7%) were transferred from other hospital services (inpatient care). In the outpatient care group, higher scores for fatigue and dyspnea were observed. Conversely, in the inpatient care group, higher scores were observed for pain, depression, and anxiety. There were significant differences between the two groups regarding the POS dimensions of meaning of life, self-feelings, and lost time. In the inpatient group, there was a longer time between diagnosis and referral to PC; however, it was also in the inpatient group that there was less time between PC referral and first PC evaluation, between PC referral and PC unit admission, and between PC referral and death. There were no significant correlations between referral times and ESAS/POS scores in the inpatient and outpatient groups.

CONCLUSIONS

The patients admitted to the Palliative Care Unit presented a high symptom burden and changes in the perception of quality of life. However, there are no statistically significant differences between one model of approach in relation to the other. It was found that poorer symptom control and quality of life were associated with a shorter referral time for PC, because this was only initiated after curative care was suspended, particularly in our institutional context. Early referrals to the PC team are essential not only to relieve symptom-related distress but also to improve treatment outcomes and quality of life for people with cancer.

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

CONTEXT

Compared to patients with solid malignancies, less is known about the role of palliative care in patients with hematologic malignancies, leading to underutilization of palliative care.

OBJECTIVES

Evaluate the timing and impact of palliative care referrals on end-of-life outcomes over a 5-year period with intent to improve the utilization of palliative care in patients with advanced hematologic malignancies.

METHODS

A retrospective cohort of patients from an urban, NCI-designated comprehensive cancer center, aged 18 years and older with a diagnosis of an advanced hematologic malignancy were separated into groups of early, late, very late, or no specialty palliative care. Logistic regression models were constructed to examine variables associated with timing of palliative care referral. Groups were compared using the Kruskal Wallis test and Dunn's test with a Bonferroni correction method.

RESULTS

222 patients with advanced hematologic malignancies who died between July 1, 20218 and June 30, 2023 were included. 50 (23%), 41 (18%), and 51 (23%) patients received an early, late, and very late palliative care referral, respectively and 80 (36%) patients did not receive a palliative care referral. There was a significantly high completion of ACP documentation among the palliative care cohorts. There was no significant difference among all cohorts in end-of-life outcomes in the last 14 or 30 days of life.

CONCLUSION

ACP documentation improved with palliative care, however, end-of-life outcomes did not. These results are likely due to the majority of late, inpatient palliative care referrals. Future studies with targeted interventions are needed to improve these outcomes.

Impact of a comprehensive rehabilitation palliative care program on the quality of life of patients with terminal cancer and their informal caregivers: a quasi-experimental study

BACKGROUND

Palliative care schemes, which include pain management, symptom control, psychosocial support and rehabilitation, aim to boost patients' quality of life, ease the burden and anxiety of informal caregivers, and ultimately provide a comprehensive approach to enhance well-being during this challenging and sensitive period. This study aims to evaluate the impact of a comprehensive rehabilitation palliative care program on the quality of life of patients with terminal cancer and their informal caregivers.

METHODS

This quasi-experimental study, conducted from August 2023 to January 2024 at outpatient clinics affiliated with the Oncology Center at Mansoura University, Egypt, focused on cancer patients and their caregivers in the palliative care department. Employing pre- and post-test phases, data were gathered using a questionnaire, EORTC QLQ C30, Hospital Anxiety and Depression Scale, Short Form Health Survey, Caregiver Burden Inventory, and Beck Anxiety Inventory. The investigation evaluated a 16-week rehabilitation program comprising exercise, psychoeducation, individual counselling, and spiritual support. Exercises, led by a physiotherapist, targeted fatigue and stress through tailored aerobic and resistance training. Psychoeducation sessions aimed to bolster coping abilities, covering fatigue management and nutrition. Trained counsellors addressed spiritual and existential concerns. Personal advisory sessions were available for individual support. Caregivers received education on rehabilitation and palliative care protocols, ensuring comprehensive patient care.

RESULTS

The mean age for cancer patients was 65.79 ± 13.85. In contrast, the mean age for primary carers was 42.05 ± 11.15. The QOL for cancer patients during the pre-test phase was 77.8 ± 7.16 and rose to 87.34 ± 14.56 during the post-test phase. Additionally, the total anxiety level of patients before the rehabilitation palliative care program was conducted was 15.45 ± 3.05 compared to 6.12 ± 3.21 after the post test phase. Furthermore, the total depression levels of the patients during the pre-test phase were 20.89 ± 9.21. However, after implementing the rehabilitation palliative care program, it decreased to 15.5 ± 6.86. In regards to the total quality of life of informal caregivers, it was measured at 67.28 ± 32.09 before conducting the program. Nevertheless, it increased to 25.95 ± 40.29 after conducting it. Additionally, the total Caregiver Burden Inventory before implementing the program was 37.45 ± 25.7, and it decreased to 29.36 ± 16.4 after conducting it. Additionally, the total score on the Beck Anxiety Inventory decreased from 45.7 ± 4.3 during the initial testing phase to 17.35 ± 23.67.

CONCLUSION

The program for rehabilitation palliative care successfully achieved its goals by enhancing the overall quality of life for cancer patients and their caregivers. Additionally, it reduced the anxiety and depression levels among the patients, as well as the anxiety and caregiver burden among the caregivers. Continue research into the effectiveness of rehabilitation palliative care programs to identify best practices, improve existing programs, and expand access to these services.

Palliative care for patients with hematologic malignancies in Germany: a nationwide survey on everyday practice and influencing factors from the perspective of treating physicians

Integrating palliative care into the treatment of patients with advanced hematological malignancies (HM) remains challenging. To explore treating physicians' perspectives on current palliative care practice and to evaluate factors influencing integration, we conducted a nationwide online survey. Based on literature and expert review, the survey addressed the importance of palliative care, communication about life-threatening conditions, challenges in establishing goals of care, and factors influencing the integration of palliative care. 207 physicians treating patients with HM in Germany participated. We used standard descriptive statistics to analyze quantitative data and a content structuring approach. Most physicians considered palliative care in HM to be very important (60.6%) and discussed life-threatening conditions with more than half of their patients (52%), especially when goals of care were changed (87.0%) or when patients raised the topic (84.0%). Disease-related factors, different professional perspectives on prognosis, and patient hopes were the main barriers to changing goals of care, but collaboration with colleagues and multidisciplinary teams provided important support. Time constraints were identified as the main barrier to integrating palliative care. The majority worked well with palliative care teams. Referral processes and conditions were perceived as minor barriers. The study highlights the need to address barriers to integrating palliative care into the management of patients with advanced HM. Future research should aim at optimizing palliative care for patients with HM.

Palliative Care and Mental Health among Pancreatic Cancer Patients in the United States: An Examination of Service Utilization and Health Outcomes

INTRODUCTION

Palliative care (PC) utilization remains low among pancreatic cancer patients. This study explores the association of PC with mental health service and pharmacotherapy utilization among pancreatic cancer patients.

METHODS

Retrospective analysis was conducted on a sample of patients in the United States with newly diagnosed pancreatic cancer using Electronic Health Record data from Optum's Integrated Claims-Clinical data set. Subsequent diagnoses of anxiety and depression and PC consultation encounters were determined using ICD-9/10 codes. Adjusted associations of mental health treatments with PC and patient characteristics were quantified using multiple logistic regression.

RESULTS

Among newly diagnosed pancreatic cancer patients (n = 4029), those with PC consultations exhibited a higher prevalence of anxiety (33.9% vs. 22.8%) and depression (36.2% vs. 23.2%). Mental health service use and pharmacotherapy varied, with the highest utilization among patients having both anxiety and depression. Treatment pattern was also influenced by age (aOR 1.832 for age <55 vs. 65-70 years). Notably, PC consultations showed no significant effect on the likelihood of documented treatment.

DISCUSSION

Our study emphasizes underutilization of PC and MH treatment for pancreatic cancer patients. These findings imply a crucial need for further investigation into palliative care's role in addressing mental health concerns among pancreatic cancer patients.

Integrating Palliative Care Into the Management of Genitourinary Malignancies

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

Enhanced supportive care: prospective cohort study of oncology patients and caregivers

OBJECTIVES

A prospective cohort study to evaluate clinical effectiveness of the enhanced supportive care (ESC) service at a comprehensive cancer centre and to explore the impact of the service on patient and caregiver outcomes and experience.

METHODS

Patients who received care under the ESC service and their caregivers were eligible. Consented patients (n=184) and caregivers (n=67) completed questionnaires at baseline, 4 weeks and 8 weeks post-ESC. Patient questionnaires assessed quality of life (QOL), symptoms, experience of ESC and health service use. Caregiver questionnaires included QOL and needs assessment. Selected patients (n=13) participated in qualitative interviews. Quantitative analysis explored differences in questionnaire responses over time (p<0.05). Qualitative data were analysed thematically.

RESULTS

Patient quantitative data showed improvements in QOL (p=0.004 for European Quality of Life Questionnaire 5 dimensions (EQ5D) health index scores) and anxiety (p=0.006) at 4 weeks, reduction in some symptoms (pain p=0.02 at 4 weeks), improvement in self-efficacy, an increase in problems being addressed and a decrease in health service use (reduction in outpatient appointments). Qualitative findings suggested patients were generally satisfied with the ESC service but identified areas for improvement such as increased awareness of ESC and earlier referral. Fewer improvements were noted for caregivers; however, they did report a decrease in unmet needs.

CONCLUSION

The ESC service had a positive impact on various patient-reported and caregiver-reported outcomes. There were also positive impacts on health service use. Increasing awareness of ESC and engaging patients at an earlier stage in the disease trajectory may further improve patient satisfaction and outcomes.

Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: a systematic review

BACKGROUND

Women with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known.

OBJECTIVES

To understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families.

METHODS

We conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization.

RESULTS

Overall there was limited access to palliative care with the few available facilities located in cities, far from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access.

CONCLUSION

Concerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.

Expectations and barriers to the utilization of specialist palliative care services among persons living with cancer in Ghana: an exploratory qualitative study

Background

The need for palliative care among patients living with cancer is increasing globally. This need is far greater in resource-constrained settings like Ghana where there is a high unmet need for palliative care services. Consequently, there are lapses in the current palliative care regime, thus, resulting in suboptimal utilization.

Objective

The study aims to explore patients living with cancer's expectations of palliative care services and examine the barriers that impede palliative care utilization.

Design

Descriptive exploratory qualitative design.

Methods

A total of 15 patients living with cancer and receiving treatment in a tertiary health facility were purposively sampled to participate in this study. Semi-structured interviews were conducted. The data were transcribed and inductively analysed following Collaizi's qualitative analysis framework.

Results

From the analysis, the findings were grouped under two main categories: perceived expectations and barriers to utilizing palliative care. The participants expected to receive meaningful communication about their condition and prognosis; they also expected to be actively involved in palliative care decision-making. Regarding the barriers, the following themes emerged: financial constraints, unfavourable health appointment schedules, problems with the distance to the health facility, poor referral and follow-up from oncology specialists and being unaware of the availability of palliative care services.

Conclusion

In conclusion, there is a need to actively involve patients and their families in all decision-making along the continuum of palliative care service delivery. The study underscores the need for Ghana to implement an integration of palliative care services in primary healthcare facilities to avert the challenges that distance to tertiary healthcare facilities poses to palliative care utilization. Service providers must implement awareness programmes to enable patients to better comprehend palliative care services.

Differential Use of Outpatient Palliative Care by Demographic and Clinical Characteristics

CONTEXT

Little is known about equity in utilization of outpatient palliative care (PC).

OBJECTIVES

To explore whether patient-level factors are associated with completing initial and follow-up visits among patients referred to outpatient PC.

METHODS

Using electronic health record data, we generated a cohort of all adults referred to outpatient PC at University of California, San Francisco October 2017-October 2021. We assessed whether demographic and clinical characteristics were associated with completion of 1) an initial PC visit and 2) at least one follow-up visit.

RESULTS

Of patients referred to outpatient PC (N = 6,871), 60% completed an initial visit; 66% of those who established care returned for follow-up. In multivariable models, patients who were less likely to complete an initial visit were older (OR per decade 0.94; 95% confidence interval [CI] 0.89-0.98), Black (OR 0.71; 95% CI 0.56-0.90), Latinx (OR 0.69; 95% CI 0.57-0.83), unpartnered (OR 0.80; 95% CI 0.71-0.90), and had Medicaid (OR 0.82; 95% CI 0.69-0.97). Among patients who completed an initial visit, those less likely to complete a follow-up visit were older (OR 0.88; 95% CI 0.82-0.94), male (OR 0.83; 95% CI 0.71-0.96), preferred a language other than English (0.71; 95% CI 0.54-0.95), and had a serious illness other than cancer (OR 0.74; 95% CI 0.61-0.90).

CONCLUSION

We found that Black and Latinx patients were less likely to complete an initial visit and those with a preferred language other than English were less likely to complete a follow-up visit. To promote equity in PC, these differences and their impact on outcomes must be explored.

Knowledge, feelings, and willingness to use palliative care in cancer patients with hematologic malignancies and solid tumors: a prospective, cross-sectional study in a comprehensive cancer center in Germany

PURPOSE

Patients with hematologic malignancies (HM) receive palliative care (PC) less often and later than patients with solid tumors (ST). Patients' lack of knowledge about PC and negative feelings about PC are barriers to their willingness to use PC. Is there a difference between patients with HM and ST in their knowledge and willingness to use PC?

METHODS

Two hundred ten patients (85 HM, 125 ST) from an oncology day clinic at a university hospital participated in this cross-sectional, questionnaire-based survey.

RESULTS

Patients with HM and ST had high knowledge and mainly positive feelings about PC. More than half of the patients answered that they would feel reassured by the use of PC, and one-third would feel anxious or hopeless. The majority of patients (58.3%) were willing to use PC. There are no significant differences between patients with HM and ST. In multiple regression analysis, perceived chance of cure and feelings of reassurance and anxiety are associated with willingness to use PC, but not with the HM/ST disease group. More than half (53.9%) of the participants would like the treating physician to choose the timing of a discussion about PC.

CONCLUSION

Our study shows a high level of knowledge and relatively positive feelings of patients about PC, with no differences between patients with HM or ST. They expect their treating physician to initiate communication about PC. Communication should include the patient's feelings about PC and their chances of a cure.

Palliative care from the perspective of cancer physicians: a qualitative semistructured interviews study

OBJECTIVE

Integrated palliative care for populations with cancer is now highly recommended. However, numerous physicians working in cancer care are still reluctant to refer patients to specialist palliative care teams. This study explores their perceptions of palliative care and factors influencing reasons to refer to specialist palliative care.

METHODS

We used a qualitative methodology based on semistructured interviews with physicians working in cancer care, in two tertiary hospitals and one comprehensive cancer centre with access to a specialist palliative care team. Forty-six physicians were invited and 18 interviews were performed until data saturation. Participants were mainly men, licensed in cancer care, 37.9 years old on average and had 13 years of professional experience. The length of interviews was on average 34 min (SD=3). Analysis was performed accordingly with the thematic analysis.

RESULTS

The data analysis found four themes: symptom management as a trigger, psychosocial support, mediation provided by interventions, and the association with terminal care or death. Palliative care integrated interventions were mainly perceived as holistic approaches that offered symptom management expertise and time. They were valued for helping in consolidating decision-making from a different or external perspective, or an 'outside look'. Several barriers were identified, often due to the confusion between terminal care and palliative care. This was further highlighted by the avoidance of the words 'palliative care', which were associated with death.

CONCLUSIONS

National policies for promoting palliative care seemed to have failed in switching oncologists' perception of palliative care, which they still consider as terminal care.

Higher Admittance to Specialized Palliative Care for Patients with High Education and Income: A Nationwide Register-Based Study

Background: While associations between socioeconomic position, that is, income and education and admittance to specialized palliative care (SPC) have been investigated previously, no prior national studies have examined admittance to all types of SPC, that is, hospital-based palliative care team/units and hospice. Aim: To investigate whether cancer patients' education and income were associated with admittance to SPC (hospital-based palliative care team/unit, hospice). Design: Data sources were several nationwide registers. The association between SPC and education and income, respectively, was investigated using logistic regression analyses. Setting/Participants: Patients dying from cancer in Denmark 2010-12 (n = 41,741). Results: In the study population, 45% had lower secondary school, and 6% had an academic education. Patients with an academic education were more often admitted to SPC than those having lower secondary school (odds ratio [OR] = 1.69; 95% confidence interval [CI]: 1.51-1.89). Patients in the highest income quartile (Q4) were more often admitted than those in the lowest income quartile (Q1) (OR = 1.46; 95% CI: 1.37-1.56). This association was stronger for hospice (OR = 1.67 (95% CI: 1.54-1.81)) than for admittance to hospital-based palliative care team/unit (OR = 1.23 (95% CI: 1.14-1.31)). Compared with patients who had lower secondary school and the lowest income, the OR of admittance to SPC among the most affluent academics was 1.96 (95% CI: 1.71-2.25). Conclusion: This nationwide study indicates that admittance to SPC was clearly associated with education and income. We believe that the associations indicate inequity. Initiatives to improve access for patients with low education or income should be established.

Palliative care referrals in patients with pulmonary arterial hypertension: The Pulmonary Hypertension Association Registry

BACKGROUND

Pulmonary arterial hypertension (PAH) is a life limiting disease with substantial symptom burden and healthcare utilization. Palliative care alleviates physical and emotional symptoms for patients with serious illness, and has been underutilized for these patients.

OBJECTIVE

To characterize patients with PAH referred to palliative care and identify predictors of referral.

METHODS

We conducted an observational study of adult patients enrolled in the Pulmonary Hypertension Association Registry from January 2015 through June 2021, performing descriptive statistics on patient characteristics at baseline for all patients and the subset referred to palliative care. These characteristics were modeled in a backwards elimination Cox regression with time to referral to palliative care as the primary outcome.

RESULTS

92 of 1,578 patients were referred to palliative care (5.8%); 43% were referred at their last visit prior to death. Referrals were associated with increasing age per decade (hazard ratio 1.35 [95% confidence interval 1.16-1.58]), lower body mass index (hazard ratio 0.97 [95% confidence interval 0.94-0.998]), supplemental oxygen use (hazard ratio 2.01 [95% confidence interval 1.28-3.16]), parenteral prostanoid use (hazard ratio 2.88 [95% confidence interval 1.84-4.51]), and worse quality of life, measured via lower physical (hazard ratio 0.97 [95% confidence interval 0.95-0.99]) and mental (hazard ratio 0.98 [95% confidence interval 0.96-0.995]) scores on the 12-item Short Form Health Survey.

CONCLUSION

Patients with PAH are infrequently referred to palliative care, even at centers of excellence. Referrals occur in sicker patients with lower quality of life scores, often close to the end of life.

Higher overall admittance of immigrants to specialised palliative care in Denmark: a nationwide register-based study of 99,624 patients with cancer

BACKGROUND

The population of immigrants in Europe is ageing. Accordingly, the number of immigrants with life-threatening diseases and need for specialised palliative care will increase. In Europe, immigrants' admittance to specialised palliative care is not well explored.

AIM

To investigate whether country of origin was associated with admittance to (I) palliative care team/unit, (II) hospice, and/or (III) specialised palliative care, overall (i.e. palliative care team/unit and/or hospice).

DESIGN

Data sources for the population cohort study were the Danish Palliative Care Database and several nationwide registers. We investigated the associations between country of origin and admittance to specialised palliative care, overall, and to type of palliative care using logistic regression analyses.

SETTING/PARTICIPANTS

In 2010-2016, 104,775 cancer patients died in Denmark: 96% were born in Denmark, 2% in other Western countries, and 2% in non-Western countries.

RESULTS

Overall admittance to specialised palliative care was higher for immigrants from other Western (OR = 1.13; 95%CI: 1.03-1.24) and non-Western countries (OR = 1.22; 95%CI: 1.08-1.37) than for the majority population. Similar results were found for admittance to palliative care teams. No difference in admittance to hospice was found for immigrants from other Western countries (OR = 1.04; 95%CI: 0.93-1.16) compared to the majority population, while lower admittance was found for non-Western immigrants (OR = 0.70; 95%CI: 0.60-0.81).

CONCLUSION

Admittance to specialised palliative care was higher for immigrants than for the majority population as higher admittance to palliative care teams for non-Western immigrants more than compensated for the lower hospice admittance. This may reflect a combination of larger needs and that hospital-based and home-based services are perceived as preferable by immigrants.

Knowledge, beliefs, and misconceptions about palliative care among older adults with cancer

INTRODUCTION

Older adults with cancer have high symptom burden and unmet needs and may benefit from palliative care (PC). However, little is known about their knowledge and understanding of PC. This study examined the knowledge, beliefs, and misconceptions about PC in older adults with cancer in the United States.

MATERIALS AND METHODS

We used data from National Cancer Institute's 2018 wave of the Health Information National Trends Survey (HINTS). A total of 370 individuals aged 65 and older with a diagnosis of cancer were included in this study. The outcomes included PC knowledge, goals, and misconceptions. The main predictors included general health status, chronic conditions, functional limitations, and types of cancer.

RESULTS

About two thirds of the sample (65.31%) did not have any knowledge of PC. Among those who had some knowledge, they had good understanding of PC goals, but also had many misconceptions about PC. Multiple regression analysis showed that older age (p < .001), racial minority (p = .021), and lower education (p = .001) was associated with lacking knowledge of PC. Individuals with some functional limitations tended to have better understanding and fewer misconceptions of PC.

DISCUSSION

The knowledge about PC is low in older adults with cancer in the US. Educational interventions need to be implemented to increase knowledge and reduce the misconceptions about PC in this population. Increasing knowledge of PC may ultimately lead to increased access to PC and improve the quality of life in this population.

Palliative radiotherapy delivery by a dedicated multidisciplinary team facilitates early integration of palliative care: A secondary analysis of routinely collected health data

BACKGROUND

Early integration of Specialist Palliative Care (SPC) with oncological care improves quality of life (QOL) of patients with advanced cancer; however, patients tend to access SPC late in their disease trajectory, if at all. Routine referral of all patients to SPC would quickly overwhelm available resources, suggesting a need for widespread accessibility of generalist PC competencies. This has been increasingly facilitated by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at the Cross Cancer Institute (CCI). Our objectives were to estimate the proportion of patients dying with breast cancer seen in consultation for PRT, and the interaction between PRT delivery and SPC referral.

METHODS

This secondary analysis of routinely collected health data examined female adults with breast cancer who died between 04/01/2013 and 03/31/2014, and had advanced disease while under the care of a CCI oncologist. Alberta Cancer Registry, electronic medical records, and Edmonton Zone Palliative Care Program data were linked. During the study period, referrals for SPC, and setting of assessment for PRT, were at the attending physicians' discretion. Clinical data were abstracted including summaries of intervals between PRT and SPC consultations, as well as from consults to death. Kaplan-Meier survival estimates, independent samples median tests, t tests of proportions, independent t tests and Chi-square tests compared groups.

RESULTS

Of 194 patients, median age at cancer diagnosis was 59 years (range 24-95yrs), median one-way distance from the CCI was 18.8km, and overall median survival (MS) was 4.4 years. 130/194 (67.0%) and 110/194 (56.7%) were assessed for PRT and by SPC respectively; 22/194 (11.3%) saw neither prior to death. Median time between first PRT consultation and death was 11.7 months (interquartile range 3.7-22.2 mos). Median time between first SPC consult and death was 2.9 mos (IQR 1-6.2 mos). 65.6% of those who never had PRT ultimately required SPC involvement, versus 52.3% of those receiving PRT. Of the 68/130 who had both, 91.2% were seen for PRT first, a median of 7.9 mos prior to seeing SPC. Patients who had SPC consultation without previous PRT were seen by PC a median 1.5 mos prior to death (IQR 0.6-4.9 mos). Patients seen for PRT outside of the PRO clinic had SPC consultation a median of 3.3 mos before death (IQR 1.2-6.2 mos), versus those seen by the PRO clinic team, who were referred a median of 6.2 mos prior (IQR 2.4-8.1 mos).

CONCLUSIONS

Fewer advanced breast cancer patients who received PRT ultimately required SPC consultation, but those who did were referred earlier in their disease course, especially if PRT assessment and delivery had taken place in the setting of a dedicated multidisciplinary team.

Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care

BACKGROUND

Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral.

AIM

To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice.

METHODS

A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported.

RESULTS

Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice.

CONCLUSION

The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.

The prognostic value of the 12-, 6-, 3- and 1-month 'Surprise Question' in cancer patients: A prospective cohort study in three hospitals

OBJECTIVE

This prospective study aimed to evaluate the performance of the 'Surprise Question' (SQ) 'Would I be surprised if this patient died in the next 12 months?' in predicting survival of 12, 6, 3 and 1 month(s), respectively, in hospitalised patients with cancer.

METHODS

In three hospitals, physicians were asked to answer SQs for 12/6/3/1 month(s) for inpatients with cancer. Sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

A total of 783 patients were included, of whom 51% died in the 12-month period after inclusion. Sensitivity of the SQ predicting death within 12 months was 0.79, specificity was 0.66, the positive predictive value was 0.71 and the negative predictive value was 0.75. When the SQ concerned a shorter survival period, sensitivities and positive predictive values decreased, whereas specificities and negative predictive values increased. In multivariable logistic regression analysis, the SQ was significantly associated with mortality (OR 3.93, 95% CI 2.70-5.71, p < 0.01).

CONCLUSIONS

The 12-month SQ predicts death in patients with cancer admitted to the hospital reasonably well. Shortening the timeframe decreases sensitivities and increases specificities. The four surprise questions may help to identify patients for whom palliative care is indicated.

A Retrospective, Single-Center Analysis of Specialized Palliative Care Services for Patients with Advanced Small-Cell Lung Cancer

Simple Summary

Patients with advanced small-cell lung cancer (SCLC) have a considerable symptom burden and may require extensive care. A crucial element of treatment for these patients is the integration of specialized palliative care (SPC). Timely integration of SPC for patients with advanced non-small cell lung cancer (NSCLC) improved quality of life and prolonged survival in large prospective trials. This study provides retrospective data for patients with SCLC with, and without SPC. The results and conclusions indicate that patients with advanced SCLC should participate in a consultation with a SPC team in a timely manner to ensure a benefit of SPC for this patient group.

Abstract

Timely integration of specialized palliative care (SPC) has been shown to improve cancer patients’ quality of life (QoL) and reduced the use of medical services. To evaluate the level of integration of SPC services for patients with advanced small-cell lung cancer (SCLC), we retrospectively analyzed medical records of patients from 2019 to 2021. Regarding the timing of referral to SPC services, we defined four cutoffs for early referral according to the current literature: (a) SPC provided ≤ 60 days after diagnosis; (b) SPC provided ≥ 60 days before death; (c) SPC provided ≥ 30 days before death; and (d) SPC provided ≥ 130 days before death. One hundred and forty-three patients (94.1%) were found to have locally advanced (stage III) or metastatic (stage IV) disease. Sixty-eight were not referred to SPC services (47.6%), whereas 75 patients received SPC (52.4%). We found a significantly higher number of referrals to SPC services for patients with higher ECOG (Eastern Cooperative Oncology Group) (i.e., ECOG ≥ 2) (p = 0.010) and patients with stage IV disease (p ≤ 0.001). The median overall survival (OS) for SCLC stage III/IV patients (n = 143) who did not receive SPC treatment was 17 months (95% CI 8.5–25.5), while those who did receive SPC treatment had a median OS of 8 months (95% CI 6.2–9.8) (p = 0.014). However, when we evaluated patients receiving SPC treatment in a timely manner before death as suggested by the different cutoffs indicated in the literature, they lived significantly longer when referred at a minimum of ≥60 or ≥130 days before death. Based on our findings, we suggest that patients with advanced SCLC should participate in a consultation with a SPC team in a timely manner to ensure a benefit of SPC for this patient group.

The effect of age on specialized palliative care use in the last year of life for patients who die of cancer: A nationwide study from Norway

INTRODUCTION

Specialized palliative care (SPC) is beneficial towards end of life because of its holistic approach to improve quality of life and comfort of patients and their families. Few studies have described how patient age, sex, comorbidities, and socioeconomic status (SES) are associated with SPC use in nonselective populations who die of cancer. This study aimed to evaluate the use of SPC in the year preceding death by all Norwegian individuals with a recent cancer diagnosis who died of cancer.

MATERIALS AND METHODS

From nationwide registries, we identified patients with a recent (<5 years) cancer diagnosis who died during 2010-2014. Using binary logistic regression models, we estimated the probability of receiving hospital-based SPC during the last year of life according to individual (age, sex, comorbidity), cancer (stage, type, and months since diagnosis), and SES (e.g., living alone, household income, and education) characteristics.

RESULTS

The analytical sample contained 45,521 patients with a median age at death of 75 years; 46% were women. The probability of receiving hospital-based SPC in the total cohort was 0.43 (95% confidence interval [CI] 0.42-0.43). Use of SPC was higher if patients were younger, female, had limited comorbidity, metastatic disease, had one the following cancer types: colorectal, pancreatic, bladder, kidney, or gastric, were diagnosed more than six months before death, and had higher SES. Adjusted model results suggested that the probability of using SPC in the last year of life for patients aged 80-89 years was 0.31 (95% CI 0.30-0.32), compared to a probability of 0.63 (95% CI 0.61-0.65) for patients aged 50-59 years. For patients ≥90 years, the probability was 0.16 (95% CI 0.15-0.18).

DISCUSSION

Less hospital-based SPC use among older patients, males, and those with lower SES indicates possible under-treatment in these groups. Future studies should be designed to determine the underlying reasons for these observed differences.

Timing of referral to outpatient palliative care for patients with haematologic malignancies

Outpatient palliative-care facilitates timely supportive-care access; however, there is a paucity of studies on the timing of referral in the outpatient setting for patients with haematologic malignancy. We examined the trend in timing of outpatient palliative-care referrals over a 10-year period in patients with haematologic malignancies at our comprehensive cancer centre. We included consecutive patients with a diagnosis of haematologic malignancy who were seen at our outpatient palliative-care clinic between 1 January 2010 and 31 December 2019. We collected data on patient characteristics, symptom burden and supportive-care interventions at outpatient palliative-care consultation. The primary outcome was time from outpatient palliative-care consultation to death or last follow-up. In all, 384 patients were referred by leukaemia (n = 143), lymphoma (n = 213), and stem cell transplant (n = 28) services. The median time from outpatient palliative-care referral to death was 3.4 years (IQR 2.4-5.3) with a significant increase in both the number of referrals per year (p = 0.047) and the timing of referral between 2010 and 2019 (p = 0.001). Patients with haematologic malignancies were referred in a timely fashion to our outpatient palliative-care clinic, with earlier and greater numbers of referrals over time.

Impact of Referring Team Characteristics on Inpatient Palliative Care Consultation Rate at a Comprehensive Cancer Center

Background: No prior study addresses the impact of admitting team characteristics on inpatient palliative care (PC) consultation rate in cancer patients. Understanding consultation rate differences among admitting service types may reveal PC access disparities for patients who would benefit from consultation. Aim: To determine the impact of admitting service characteristics (teaching vs. nonteaching and surgical vs. medical) on inpatient PC consultation rates. Methods: A six-month cross-sectional study was performed at an academic comprehensive cancer center. Inpatient PC consultations and follow-up visits were compared to total admissions by admitting service category. Results: Five thousand six hundred ninety-seven admissions resulted in 710 new PC consultations and 2494 follow-up visits. Patients admitted to medical services had highest odds of PC consultation, while data for teaching services were mixed. There was no difference in follow-up visits. Conclusions: Significant differences between medical and surgical service PC consultation rates may indicate specialty PC access disparities solely based on their admitting service.

Barreiras para o encaminhamento para o cuidado paliativo exclusivo: a percepção do oncologista

RESUMO Pacientes com câncer avançado demandam cuidados paliativos. Nosso objetivo foi o de avaliar as barreiras ao encaminhamento ao cuidado paliativo na percepção de oncologistas. Desenvolvemos um estudo com oncologistas de uma instituição de referência nacional, questionando-os quanto a aspectos da sua formação acadêmica, à compreensão dos significados de cuidados paliativos, bem como limites e benefícios do encaminhamento de pacientes a uma unidade de cuidados paliativos exclusivos. A análise qualitativa foi realizada por meio da técnica de análise de conteúdo de Bardin. Participaram 19 oncologistas, que, apesar de definirem o cuidado paliativo com características multidisciplinares, voltado para doença avançada, com o objetivo de melhorar a qualidade de vida, relataram dificuldades no encaminhamento relacionadas ao próprio profissional, expectativas dos pacientes ou familiares, obstinação terapêutica e características institucionais. A criação de um ‘time consultor’ nas unidades de cuidados usuais foi a principal estratégia relatada como potencial facilitadora para essa transição de cuidados. Concluímos que a deliberação do cuidado paliativo exclusivo para pacientes com câncer avançado é uma tarefa difícil, que perpassa diferentes barreiras. A dicotomia existente entre ‘tratamento’ e ‘paliação’ na modalidade do cuidado paliativo exclusivo deve ser repensada, contrapondo a ideia do cuidado paliativo ofertado a partir do diagnóstico.

Patient-Centered Palliative Care for Patients With Advanced Lung Cancer

The evidence base demonstrating the benefits of an early focus on palliative care for patients with serious cancers, including advanced lung cancer, is substantial. Early involvement of specialty-trained palliative care clinicians in the care of patients with advanced lung cancer improves patient-reported outcomes, such as quality of life, and health care delivery, including hospice utilization. Since the time that many of these palliative care trials were conducted, the paradigm of cancer care for many cancers, including lung cancer, has changed dramatically. The majority of patients with advanced lung cancer are now treated with immune checkpoint inhibitors or targeted therapies, both of which have had a significant impact on patient's experience and outcomes. With this changing landscape of lung cancer therapeutics, patients are facing new and different challenges, including dealing with novel side effect profiles and coping with greater uncertainty regarding their prognosis. Patients who are living longer with their advanced cancer also struggle with how to address survivorship issues, such as sexual health and exercise, and decision making about end-of-life care. Although palliative care clinicians remain well-suited to address these care needs, they may need to learn new skills to support patients treated with novel therapies. Additionally, as the experience of patients with advanced lung cancer is becoming more varied and individualized, palliative care research interventions and clinical programs should also be delivered in a patient-centered manner to best meet patient's needs and improve their outcomes. Tailored and technology-based palliative care interventions are promising strategies for delivering patient-centered palliative care.

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.

Early palliative/supportive care in acute myeloid leukaemia allows low aggression end-of-life interventions: observational outpatient study

OBJECTIVES

Early palliative supportive care has been associated with many advantages in patients with advanced cancer. However, this model is underutilised in patients with haematological malignancies. We investigated the presence and described the frequency of quality indicators for palliative care and end-of-life care in a cohort of patients with acute myeloid leukaemia receiving early palliative supportive care.

METHODS

This is an observational, retrospective study based on 215 patients consecutively enrolled at a haematology early palliative supportive care clinic in Modena, Italy. Comprehensive hospital chart reviews were performed to abstract the presence of well-established quality indicators for palliative care and for aggressiveness of care near the end of life.

RESULTS

131 patients received a full early palliative supportive care intervention. All patients had at least one and 67 (51%) patients had four or more quality indicators for palliative care. Only 2.7% of them received chemotherapy in the last 14 days of life. None underwent intubation or cardiopulmonary resuscitation and was admitted to intensive care unit during the last month of life. Only 4% had either multiple hospitalisations or two or more emergency department access. Approximately half of them died at home or in a hospice. More than 40% did not receive transfusions within 7 days of death. The remaining 84 patients, considered late referrals to palliative care, demonstrated sensibly lower frequencies of the same indicators.

CONCLUSIONS

Patients with acute myeloid leukaemia receiving early palliative supportive care demonstrated high frequency of quality indicators for palliative care and low rates of treatment aggressiveness at the end of life.

Prevalence and timing of specialist palliative care access among advanced cancer patients and association with hospital death

Background

Patients with advanced cancer have poor quality of life and high utilisation of acute healthcare services. Early access to palliative care has been shown to improve quality of life as well as reduce acute healthcare utilisation and costs.

Objectives

To determine the prevalence and timing of hospital-based specialist palliative care reviews for patients with advanced cancer known to National Cancer Centre Singapore. We also explored the association between specialist palliative care review and place of death.

Methods

A retrospective study of patients with Stage 4 cancer who died in a 2-year period from 1 January 2016 to 31 December 2017 (regardless of their date of diagnosis) and who received treatment in National Cancer Centre Singapore (NCCS).

Results

A total of 2572 patients were included, of which 1226 (47.7%) had at least one inpatient or outpatient specialist palliative care consultation. Those who had their first specialist palliative care review 30 days or less before death had a 2.01 (95% CI 1.62 to 2.49, p < 0.001) increased odds of hospital death while those who had the first hospital-based palliative care review more than 30 days before death a 0.76 (95% CI 0.62 to 0.93, p = 0.009) reduced odds of hospital death.

Conclusions

Our study found inadequate and late access to specialist palliative care among advanced cancer patients. Furthermore, late access to specialist palliative care was associated with hospital death. There is an urgent need to improve access to specialist palliative care in order to improve patient outcomes.

Incorporating palliative care principles to improve patient care and quality of life in urologic oncology

Palliative care - specialized healthcare focused on improving quality of life for patients with serious illnesses - can help urologists to care for patients with unmet symptom, coping and communication needs. Society guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend incorporating palliative care into standard oncological care, based on multiple randomized trials demonstrating that it significantly improves physical well-being, patient satisfaction and goal concordant care. Misconceptions regarding the objective and ideal timing of palliative care are common; a key concept is that palliative care and treatments seeking to cure or prolong life are not mutually exclusive. Urologists are well positioned to champion the integration of palliative care into surgical urologic oncology and should be aware of palliative care guidelines, indications for palliative care use and how the field of urologic oncology can adopt best practices.

Trends in specialized palliative care referrals at an oncology center from 2007 to 2019

BACKGROUND

Early referral to palliative care, at least 3 months before death, should be a standard of care in oncological practice. Real life data in this setting are invaluable since they provide a picture of everyday practice and serve as the basis for future improvements.

METHODS

We conducted a retrospective cohort assessment of all patients referred to our specialized palliative care (SPC) services at the Institute of Oncology, Ljubljana, Slovenia. Our analysis includes patient referrals between 2007 and 2019.

RESULTS

During the above-specified time period of 13 years, 3234 patients were referred for SPC services at our institution. The median age at SPC referral was 67 years. The majority of patients (63%) were assessed only once, while 31% of patients were seen on more than one occasion. Median time from SPC referral to death was 25 days for the whole group. 1693 patients (52.7%) were referred to SPC in the last 30 days before death, 785 (25.8%) patients between 31 and 90 days and 652 (21.4%) patients more than 3 months before death. Neither age nor sex correlated with the duration of referral time. However, there was a strong correlation between the year of referral to palliative care and the duration of palliative care service (ρ = 0.19, p < 0.001). The median referral to death interval for lymphoma patients and breast cancer patients were 15 and 18 days, respectively, and the median referral to death interval for colorectal cancer and lung tumor patients were 34 and 26 days before death, respectively.

CONCLUSION

Throughout the existence of our SPC services we have observed a positive trend in the number of referrals, a lengthening of time between referral and death, as well as an increase in the proportion of patients with an early referral to SPC (more than 3 months before death). Neither age nor sex correlated with the length of referral time.

Patterns of Specialty Palliative Care Utilization Among Patients Receiving Palliative Radiation Therapy

CONTEXT

Palliative radiation therapy (RT) is frequently used to ameliorate cancer-associated symptoms and improve quality of life.

OBJECTIVES

To examine how palliative care (PC) as a specialty is integrated at the time of RT consultation for patients with advanced cancer.

METHODS

We retrospectively reviewed 162 patients with metastatic cancer who received palliative RT at our institution (7/2017-2/2018). Fisher's exact test identified differences in incidence of receiving any specialty PC. Logistic regression analyses determined predictors of receiving PC.

RESULTS

Of the 74 patients (46%) who received any specialty PC, 24 (32%) initiated PC within four weeks of RT consultation. The most common reasons for specialty PC initiation were pain (64%) and goals of care/end-of-life care management (23%). Referrals to specialty PC were made by inpatient care teams (48.6%), medical oncologists (48.6%), radiation oncologists (1.4%), and self-referring patients (1.4%). Patients with pain at RT consultation had a higher incidence of receiving specialty PC (58.7% vs. 37.4%, P = 0.0097). There was a trend toward decreased PC among patients presenting with neurological symptoms (34.8% vs. 50%, P = 0.084). On multivariable analysis, receiving specialty PC significantly differed by race (non-white vs. white, odds ratio [OR] = 6.295 [95% CI 1.951-20.313], P = 0.002), cancer type (lung vs. other histology, OR = 0.174 [95% CI 0.071-0.426], P = 0.0006), and RT consultation setting (inpatient vs. outpatient, OR = 3.453 [95% CI 1.427-8.361], P = 0.006).

CONCLUSION

Fewer than half of patients receiving palliative RT utilized specialty PC. Initiatives are needed to increase PC, especially for patients with lung cancer and neurological symptoms, and to empower radiation oncologists to refer patients to specialty PC.

A Prognostic Model to Facilitate Palliative Care Referral in Oncology Outpatients

Purpose

We aimed to develop a prognostic model to assist palliative care referral at least 3 months before death in advanced cancer patients treated at an outpatient medical oncology clinic.

Materials and Methods

In this prospective cohort study, a total of 200 patients were enrolled at a tertiary cancer center in South Korea. The major eligibility criterion was an expected survival of less than a year as estimated by their oncologists. We analyzed the influences of known prognostic factors along with chemotherapy status, mid-arm circumference, and triceps skinfold thickness on survival time.

Results

The mean age of the patients was 64.5 years, 36% were female, and the median survival time was 7.6 months. In the multivariate analysis, we found six significant factors related to poor survival: a poor Eastern Cooperative Oncology Group (ECOG) performance status (≥ 2), not undergoing chemotherapy, anorexia, a low lymphocyte level (< 12%), a high lactate dehydrogenase (LDH) level (≥ 300 IU/L), and a low mid-arm circumference (< 23 cm). We developed a prognostic model (score, 0–8.0) to predict 3-month survival based on the multivariate analysis. Patients who scored ≥ 4.0 points had a short survival of less than 3 months (p < 0.001). The discriminating ability of the prognostic model using the area under the receiver operating characteristic curve was 0.88.

Conclusion

The prognostic model using ECOG performance status, chemotherapy status, anorexia, lymphocytes, LDH, and mid-arm circumference can predict 3-month survival in medical oncology outpatients. It can alert oncologists to refer patients to palliative care specialists before it is too late.

"I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments

BACKGROUND

National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory.

OBJECTIVE

To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites.

METHODS

A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis.

RESULTS

Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity).

CONCLUSIONS

The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.

Current status of intensive end-of-life care in children with hematologic malignancy: a population-based study

Background

Adult patients with hematologic malignancies are less likely to receive palliative care and more likely to accept intensive anti-cancer treatments until end-of-life than those with solid tumors, but limited data are available regarding the quality of end-of-life care (EOLC) for children with hematologic malignancies. To improve the quality of EOLC for children with hematologic malignancies, the aims of this study were (i) to compare intensive EOLC between children with hematologic malignancies and those with solid tumors; and (ii) to describe factors associated with intensive EOLC in children with hematologic malignancies.

Methods

We retrospectively reviewed 0- to 18-year-old patients with cancer, who died in hospital between April 2012 and March 2016 in Japan using the Diagnosis Procedure Combination per-diem payment system. Indicators of intensive inpatient EOLC were defined as intensive care unit admission, cardiopulmonary resuscitation (CPR), intubation and/or mechanical ventilation, hemodialysis, or extra-corporeal membrane oxygenation in the last 30 days of life, or intravenous chemotherapy in the last 14 days. We determined factors associated with intensive EOLC using regression models. Data regarding use of blood transfusion were also obtained from the database.

Results

Among 1199 patients, 433 (36%) had hematological malignancies. Children with hematologic malignancies were significantly more likely than those with solid tumors to have intubation and/or mechanical ventilation (37.9% vs. 23.5%), intensive care unit admission (21.9% vs. 7.2%), CPR (14.5% vs. 7.7%), hemodialysis (13.2% vs. 3.1%) or extra-corporeal membrane oxygenation (2.5% vs. 0.4%) in their last 30 days, or intravenous chemotherapy (47.8% vs. 18.4%; all P < .01) within their last 14 days of life. Over 90% of children with hematological malignancies received a blood transfusion within the last 7 days of life. For hematological malignancies, age under 5 years was associated with CPR and ≥ 2 intensive EOLC indicators. Longer hospital stays had decreased odds of ≥ 2 intensive EOLC indicators.

Conclusion

Children with hematologic malignancies are more likely to receive intensive EOLC compared to those with solid tumors. A younger age and shorter hospital stay might be associated with intensive EOLC in children with hematologic malignancies.

Palliative care referral in cancer patients with regard to initial cancer prognosis: a population-based study

OBJECTIVES

More than half of cancer patients require palliative care; however, inequality in access and late referral in the illness trajectory are major issues. This study assessed the cumulative incidence of first hospital-based palliative care (HPC) referral, as well as the influence of patient-, tumor-, and care-related factors.

STUDY DESIGN

This is a retrospective population-based study.

METHODS

The study included patients from the 2014 population-based cancer registry of Gironde, France. International Classification of Diseases, Tenth Revision, coding for palliative care identified HPC referrals from 2014 to 2018. The study included 8424 patients. Analyses considered the competing risk of death and were stratified by initial cancer prognosis (favorable vs unfavorable [if metastatic or progressive cancer]).

RESULTS

The 4-year incidence of HPC was 16.7% (95% confidence interval, 16.6-16.8). Lung cancer led to more referrals, whereas breast, colorectal, and prostatic locations were associated to less frequent HPC compared with other solid tumors. Favorable prognosis central nervous system tumors and unfavorable prognosis hematological malignancies also showed less HPC. The incidence of HPC was higher in tertiary centers, particularly for older patients. In the favorable prognosis subgroup, older and non-deprived patients received more HPC. In the unfavorable prognosis subgroup, the incidence of HPC was lower in patients who lived in rural areas than those who lived in urban areas.

CONCLUSIONS

One-sixth of cancer patients require HPC. Some factors influencing referral depend on the initial cancer prognosis. Our findings support actions to improve accessibility, especially for deprived patients, people living in rural areas, those with hematological malignancies, and those treated outside tertiary centers. In addition, consideration of age as factor of HPC may allow for improved design of the referral system.

Sociodemographic Disparities in Access to Hospice and Palliative Care: An Integrative Review

BACKGROUND

There is growing evidence of disparities in access to hospice and palliative care services to varying degrees by sociodemographic groups. Underlying factors contributing to access issues have received little systematic attention.

OBJECTIVE

To synthesize current literature on disparities in access to hospice and palliative care, highlight the range of sociodemographic groups affected by these inequities, characterize the domains of access addressed, and outline implications for research, policy, and clinical practice.

DESIGN

An integrative review comprised a systematic search of PubMed, Embase, and CINAHL databases, which was conducted from inception to March 2020 for studies outlining disparities in hospice and palliative care access in the United States. Data were analyzed using critical synthesis within the context of a health care accessibility conceptual framework. Included studies were appraised on methodological quality and quality of reporting.

RESULTS

Of the articles included, 80% employed non-experimental study designs. Study measures varied, but 70% of studies described differences in outcomes by race, ethnicity, or socioeconomic status. Others revealed disparate access based on variables such as age, gender, and geographic location. Overall synthesis highlighted evidence of disparities spanning 5 domains of access: Approachability, Acceptability, Availability, Affordability, and Appropriateness; 60% of studies primarily emphasized Acceptability, Affordability, and Appropriateness.

CONCLUSIONS

This integrative review highlights the need to consider various stakeholder perspectives and attitudes at the individual, provider, and system levels going forward, to target and address access issues spanning all domains.

The palliative care needs and experiences of people with advanced head and neck cancer: A scoping review

BACKGROUND

The palliative care needs of people with advanced head and neck cancer pose unique complexities due to the impact the illness has on eating, speaking, appearance and breathing. Examining these needs would help provide guidance about developing relevant models of care and identify gaps in research knowledge.

AIM

To identify and map out the palliative care needs and experiences for people with advanced head and neck cancer.

DESIGN

A scoping literature review following the methods described by the Joanna Briggs Institute.

DATA SOURCES

An electronic search of the literature was undertaken in MEDLINE (Ovid), EMBASE and CINAHL covering the years January 1996 to January 2019.

RESULTS

People with advanced head and neck cancer often had palliative care needs but there was variability in the timing and access to relevant services. A high prevalence of interventions, for example hospital admissions were needed even during the last month of life. This was not necessarily negated with early engagement of palliative care. Dissonance between patients and family carers about information needs and decision-making was an additional complexity. Studies tended to be descriptive in nature, and often involved a single centre.

CONCLUSION

This scoping review demonstrates the complexity of care for people with advanced head and neck cancer and the issues related to the current healthcare systems. Focus on appropriate referral criteria, increased integration and coordination of care and robust evaluation of specific care components seems key. Linkage between research and service design delivery across teams, disciplines and care settings seems pertinent.

Duration of palliative care involvement and cancer care aggressiveness near the end of life

OBJECTIVES

Previous studies have found an association between aggressive cancer care and lower quality end of life. Despite international recommendations, late or very late referral to palliative care seems frequent. This study aimed to evaluate the association between the duration of involvement of a palliative care team (PCT), and aggressive cancer care, and to identify factors associated with aggressive cancer care.

METHODS

We performed an observational retrospective study in a single academic teaching hospital. In total, 561 inpatients with solid tumours or haematological malignancies were included. Patients followed by a PCT for at least 1 month before death were classified in the palliative care group. Aggressive cancer care was defined as: hospitalisations and/or a new line of chemotherapy within the last month of life, location of death, the use of chemotherapy in the last 2 weeks and hospice admissions within the last 3 days of life.

RESULTS

Among the 561 patients, 241 (43%) were referred to the PCT; 89 (16%) were followed by the PCT for a month or more before death. In the last 2 weeks of life, 124 (22%) patients received chemotherapy, 110 (20%) died in an acute care unit. At least one criterion of aggressive cancer care was found in 395 patients overall (71%). Aggressive cancer care was significantly less frequent when the PCT referral occurred >1 month before death (p<0.0001).

CONCLUSION

More studies are needed to understand reasons for late referrals despite international recommendations encouraging integrative palliative care.

ETHICS APPROVAL

The study was approved by the Grenoble Teaching Hospital ethics committee, and by the CNIL (French national commission for data privacy; Commission Nationale de l'Informatique et des Libertés) under the number 1987785 v 0. Due to ethical and legal restrictions, data are only available on request.

Delivery of Palliative Care in Acute Care Hospitals: A Population-Based Retrospective Cohort Study Describing the Level of Involvement and Timing of Inpatient Palliative Care in the Last Year of Life

Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.

Racial and ethnic disparities in palliative care utilization among gynecological cancer patients

BACKGROUND

Palliative care (PC) is recommended for gynecological cancer patients to improve survival and quality-of-life. Our objective was to evaluate racial/ethnic disparities in PC utilization among patients with metastatic gynecologic cancer.

METHODS

We used data from the 2016 National Cancer Database (NCDB) and included patients between ages 18-90 years with metastatic (stage III-IV) gynecologic cancers including, ovarian, cervical and uterine cancer who were deceased at last contact or follow-up (n = 124,729). PC was defined by NCDB as non-curative treatment, and could include surgery, radiation, chemotherapy, and pain management or any combination. We used multivariable logistic regression to evaluate racial disparities in PC use.

RESULTS

The study population was primarily NH-White (74%), ovarian cancer patients (74%), insured by Medicare (47%) or privately insured (36%), and had a Charlson-Deyo score of zero (77%). Over one-third of patients were treated at a comprehensive community cancer program. Overall, 7% of metastatic gynecologic deceased cancer patients based on last follow-up utilized palliative care: more specifically, 5% of ovarian, 11% of cervical, and 12% of uterine metastatic cancer patients. Palliative care utilization increased over time starting at 4% in 2004 to as high as 13% in 2015, although palliative care use decreased to 7% in 2016. Among metastatic ovarian cancer patients, NH-Black (aOR:0.87, 95% CI:0.78-0.97) and Hispanic patients (aOR:0.77, 95% CI:0.66-0.91) were less likely to utilize PC when compared to NH-White patients. Similarly, Hispanic cervical cancer patients were less likely (aOR:0.75, 95% CI:0.63-0.88) to utilize PC when compared to NH-White patients.

CONCLUSIONS

PC is highly underutilized among metastatic gynecological cancer patients. Racial disparities exist in palliative care utilization among patients with metastatic gynecological cancer.