Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.

Occurrence of Advance Care Planning and Hospital Course in Patients Admitted for Coronavirus Disease 2019 (COVID-19) During the Pandemic

Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic highlighted the importance of understanding patients’ goals, values, and medical care preferences given the high morbidity and mortality. We aimed to examine rates of advance care planning (ACP) documentation along with hospital course differences in the absence or presence of ACP among hospitalized patients with COVID-19.

Methods

This retrospective cohort study was performed at a single tertiary academic medical center. All adults admitted between March 1, 2020, and June 30, 2020, for COVID-19 were included. Demographics, ACP documentation rates, presence of ACP forms, palliative care consultation (PCC) rates, code status, and hospital outcome data were collected. Data were analyzed with multivariable analysis to identify predictors of ACP documentation.

Results

Among 356 patients (mean age 60.0, 153 (43%) female), 97 (27.2%) had documented ACP and 20 (5.6%) had completed ACP forms. In patients with documented ACP, 52.4% (n = 55) de-escalated care to do-not-resuscitate (DNR)-limited or comfort measures. PCC occurred rarely (<8%), but 78% (n = 21) of those consulted de-escalated care. Being admitted to the intensive care unit (ICU) (OR = 11.1, 95% CI = 5.9-21.1), mechanical intubation (OR = 15.8, 95% CI = 7.4-32.1), and discharge location other than home (OR = 11.3, 95% CI = 5.7-22.7) were associated with ACP documentation.

Conclusions

This study found low ACP documentation and PCC rates in patients admitted for COVID-19. PCC and completion of ACP were associated with higher rates of care de-escalation. These results support the need for pro-active ACP and PCC for patients admitted for serious illnesses, like COVID-19, to improve goal-informed care.

Palliative specialty care availability for adults in community oncology practices

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Background: The American Society of Clinical Oncology recommends integration of palliative care in patients with advanced cancer. Studies have shown the availability of palliative care services, especially in outpatient settings, varies widely across practice sites; factors associated with outpatient palliative care clinic availability remain unknown. Our study describes the presence and characteristics of palliative care resources in community oncology practices. Methods: Analyses used data from the 2015 Cancer Care Delivery Research (CCDR) Landscape Assessment of National Cancer Institute Community Oncology Research Program (NCORP) practices (funding support provided by 2UG1CA189824). Oncology practices were surveyed regarding availability of specialty providers and supportive services, including palliative care, as reported by designated CCDR leads. Descriptive statistics describe availability of providers and services, and logistic regression models identify practice characteristics associated with supportive/palliative care specialist availability. Results: 216 non-pediatric exclusive NCORP practice groups were included in analyses. Characteristics are shown in Table. A majority of practices had palliative care specialists (76%), oncology certified nurses (95%), and advance practice providers (80%); 45% had nurse navigators for oncology. 76% of practices had inpatient palliative care consultation services, but only 36% had a dedicated outpatient palliative care clinic. Multivariable analyses demonstrated practices with Medicaid and/or uninsured patient volumes > 25% (Odds Ratio (OR) = 2.5, p = 0.020), more oncology providers (OR = 1.02, p = 0.025), survivorship clinic availability (OR = 2.5, p = 0.005), and who participated in the Quality Oncology Practice Initiative (QOPI) (OR = 2.0, p = 0.039) were significantly more likely to have an outpatient palliative care clinic. Conclusions: Most community oncology practices reported having palliative care specialists, although only a third had a dedicated outpatient palliative care clinic. Newly discovered factors associated with increased odds of having an outpatient palliative care clinic can inform future efforts to expand the availability of outpatient palliative care clinics within community oncology practices.[Table: see text]