Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center

Purpose.

Palliative care consultation services are now available in the majority of cancer centers, yet most referrals to palliative care occur late. We previously found that the term “palliative care” was perceived by oncology professionals as a barrier to early patient referral. We aimed to determine whether a service name change to supportive care was associated with earlier referrals.

Patients and Methods.

Records of 4,701 consecutive patients with a first palliative care consultation before (January 2006 to August 2007) and after (January 2008 to August 2009) the name change were analyzed, including demographics and dates of first registration to hospital, advanced cancer diagnosis, palliative care consultation, and death. One-sample proportions tests, median tests, χ² tests, and log-rank tests were used to identify group differences.

Results.

The median age was 59 years, 50% were male, and 90% had solid tumors. After the name change, we found: (a) a 41% greater number of palliative care consultations (1,950 versus 2,751 patients; p < .001), mainly as a result of a rise in inpatient referrals (733 versus 1,451 patients; p < .001), and (b) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio [HR], 0.85; p < .001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; p < .001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; p < .001).

Conclusion.

The name change to supportive care was associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitates earlier access to supportive/palliative care and should be established in more centers.     

Aggressiveness of care in a prospective cohort of patients with advanced NSCLC

BACKGROUND: Optimal end of life care of patients with terminal cancer is poorly understood. In this study, the aggressiveness of care is described in a cohort of patients with newly diagnosed advanced nonsmall-cell lung cancer (NSCLC). METHODS: Patients within 8 weeks of diagnosis of stage IIIb (with effusions) or IV NSCLC were enrolled in a study to examine the feasibility of involving palliative care services early in the provision of cancer care. Participants received standard oncology treatment and integrated palliative care. All patients were followed prospectively to assess anticancer therapy usage, hospital admissions, hospice utilization, and location of death. RESULTS: At the time of analysis, 40/46 (87%) of enrolled patients had died, with a median length of follow-up of 29.3 months. Aggressive care measures in the final month of life included rates of anticancer therapy (40%), emergency department visits (48%), and hospital admissions (50%). Sixty-five percent of patients received hospice care before death, with a median length of stay of 16 days. Patients with heightened baseline anxiety and mood symptoms were more likely to receive anticancer therapy at the end of life compared with those without such symptoms. CONCLUSIONS: This study demonstrates the frequent use of aggressive measures at the end of life among patients with advanced NSCLC in a tertiary care center, as shown by the number of patients receiving anticancer therapy within 30 days of death and brief utilization of hospice services. Further research is needed to identify predictors of aggressive care and to develop interventions enhancing decision-making at the end of life.     

Use of Palliative Care Services in a Tertiary Cancer Center

Background.

Despite increasing prevalence of palliative care (PC) services in cancer centers, most referrals to the service occur exceedingly late in the illness trajectory. Over the years, we have made several attempts to promote earlier patient access to our PC program, such as changing the name of our service from PC to supportive care (SC). This study was conducted to determine the use of PC/SC service over the past 8 years.

Methods.

We reviewed billing data for all PC/SC encounters. We examined five metrics for use: inpatient consultations as a percentage of hospital admissions, ratio of inpatient consultations to average number of operational beds, time from hospital registration to outpatient consultation, time from advanced cancer diagnosis to consultation, and time from first outpatient consultation to death/last follow-up.

Results.

Over the years, we found a consistent increase in patient referrals to the PC/SC program. In the inpatient setting, we found approximate doubling of the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds (from 10% to 19% and from 2.4 to 4.9, respectively; p < .001). In the outpatient setting, we observed variations in referral pattern between oncology services, but, overall, the time from consultation to death/last follow-up increased from 4.8 months to 7.9 months (p = .001), which was accompanied by a significant decrease in the interval to consultation from hospital registration and advanced cancer diagnosis (p < .001).

Conclusion.

We have observed a consistent annual increase in new patient referrals as well as earlier access for outpatient referrals to our SC service, supporting increased use of palliative care at our cancer center.

Implications for Practice:

In response to accumulating evidence on the benefits of palliative care (PC) referral to oncology patients, efforts are being made to increase PC use. This study, conducted at MD Anderson Cancer Center, demonstrates consistent annual growth in PC referrals, which was accompanied by a significant increase in the outpatient referral of patients with nonadvanced cancer and earlier referral of those with advanced cancer. However, significant variations in the referral patterns between oncology services were observed. These results have implications for other cancer centers looking to enhance use of PC services by having a business model that allows for appropriate space and staff expansion.     

End-of-life care pathways as tools to promote and support a good death: a critical commentary

This paper calls into question whether and how end-of-life care pathways facilitate the accomplishment of a 'good death'. Achieving a 'good death' is a prominent social and political priority and an ideal which underpins the philosophy of hospice and palliative care. End-of-life care pathways have been devised to enhance the care of imminently dying patients and their families across care settings and thereby facilitate the accomplishment of a 'good death'. These pathways have been enthusiastically adopted and are now recommended by governments in the UK as 'best practice' templates for end-of-life care. However, the literature reveals that the 'good death' is a nebulous, fluid concept. Moreover, concerns have been articulated regarding the efficacy of care pathways in terms of their impact on patient care and close analysis of two prominent end-of-life pathways reveals how biomedical aspects of care are privileged. Nonetheless drawing on a diverse range of evidence the literature indicates that end-of-life care pathways may facilitate a certain type of 'good death' and one which is associated with the dying process and framed within biomedicine.     

Patient‐centered,evidence‐based,and cost‐conscious cancer care across the continuum: Translating the Institute of Medicine report into clinical practice

In 2013, the Institute of Medicine (IOM) concluded that cancer care in the United States is in crisis. Patients and their families are not receiving the information that they need to make informed decisions about their cancer care. Many patients do not have access to palliative care and too few are referred to hospice at the appropriate point in their disease trajectory. Simultaneously, there is a growing demand for cancer care with increases in new cancer diagnoses and the number of patients surviving cancer. Furthermore, there is a workforce shortage to care for this growing and elderly population. The IOM's report, Delivering High‐Quality Cancer Care: Charting a New Course for a System in Crisis, outlined recommendations to improve the quality of cancer care. This article provides an overview of the IOM report and highlights the recommendations that are most relevant to practicing clinicians who care for patients with cancer across the continuum. The implementation of the recommendations in clinical practice will require better patient‐clinician communication, improved care coordination, targeted clinician training, effective dissemination of evidence‐based guidelines and strategies for eliminating waste, and continuous quality assessment and improvement efforts. CA Cancer J Clin 2014;64:408–421. © 2014 American Cancer Society.     

Toward population-based indicators of quality end-of-life care: testing stakeholder agreement

BACKGROUND: Quality indicators (QIs) are tools designed to measure and improve quality of care. The objective of this study was to assess stakeholder acceptability of QIs of end-of-life (EOL) care that potentially were measurable from population-based administrative health databases. METHODS: After a literature review, the authors identified 19 candidate QIs that potentially were measurable through administrative databases. A modified Delphi methodology, consisting of multidisciplinary panels of cancer care health professionals in Nova Scotia and Ontario, was used to assess agreement on acceptable QIs of EOL care (n = 21 professionals; 2 panels per province). Focus group methodology was used to assess acceptability among patients with metastatic breast cancer (n = 16 patients; 2 groups per province) and bereaved family caregivers of women who had died of metastatic breast cancer (n = 8 caregivers; 1 group per province). All sessions were audiotaped, transcribed verbatim, and audited, and thematic analyses were conducted. RESULTS: Through the Delphi panels, 10 QIs and 2 QI subsections were identified as acceptable indicators of quality EOL care, including those related to pain and symptom management, access to care, palliative care, and emergency room visits. When Delphi panelists did not agree, the principal reasons were patient preferences, variation in local resources, and benchmarking. In the focus groups, patients and family caregivers also highlighted the need to consider preferences and local resources when examining quality EOL care. CONCLUSIONS: The findings of this study should be considered when developing quality monitoring systems. QIs will be most useful when stakeholders perceive them as measuring quality care.     

Religious coping and behavioral disengagement: opposing influences on advance care planning and receipt of intensive care near death

Objective: This study examines the relationships between methods of coping with advanced cancer, completion of advance care directives, and receipt of intensive, life‐prolonging care near death. Methods: The analysis is based on a sample of 345 patients interviewed between January 1, 2003, and August 31, 2007, and followed until death as part of the Coping with Cancer Study, an NCI/NIMH‐funded, multi‐site, prospective, longitudinal, cohort study of patients with advanced cancer. The Brief COPE was used to assess active coping, use of emotional‐support, and behavioral disengagement. The Brief RCOPE was used to assess positive and negative religious coping. The main outcome was intensive, life‐prolonging care near death, defined as receipt of ventilation or resuscitation in the last week of life. Results: Positive religious coping was associated with lower rates of having a living will (AOR = 0.39, p = 0.003) and predicted higher rates of intensive, life‐prolonging care near death (AOR, 5.43; p<0.001), adjusting for other coping methods and potential socio‐demographic and health status confounds. Behavioral disengagement was associated with higher rates of DNR order completion (AOR, 2.78; p = 0.003) and predicted lower rates of intensive life‐prolonging care near death (AOR, 0.20; p = 0.036). Not having a living will partially mediate the influence of positive religious coping on receipt of intensive, life‐prolonging care near death. Conclusion: Positive religious coping and behavioral disengagement are important determinants of completion of advance care directives and receipt of intensive, life‐prolonging care near death. Copyright © 2011 John Wiley & Sons, Ltd.     

Factors contributing to evaluation of a good death from the bereaved family member's perspective

Background: Although it is important to achieve a good death in Japan, there have been no studies to explore factors associated with a good death. The aim of this study was to explore factors contributing to a good death from the bereaved family members' perspectives, including patient and family demographics and medical variables. Methods: A cross‐sectional anonymous questionnaire survey for bereaved family members of cancer patients who had died in a regional cancer center and a medical chart review were conducted. We measured the results from the Good Death Inventory and family demographics. In addition, we extracted patient demographics, medical variables, and medical interventions in the last 48 h before death from a medical chart review. Results: Of the 344 questionnaires sent to bereaved family members, 165 responses were analyzed (48%). We found, first, that death in the palliative care unit was more likely to be described as a good death compared with death on a general ward. Some significant characteristics were ‘environmental comfort,’ ‘physical and psychological comfort,’ ‘being respected as an individual,’ and ‘natural death.’ Second, we found that a patient's and family member's age and other demographic factors significantly correlated with an evaluation of a good death. In addition, life prolongation treatment and aggressive treatment such as chemotherapy in the last 2 weeks of life were barriers to attainment of a good death. Moreover, appropriate opioid medication contributed to a good death. Conclusion: Withholding aggressive treatment and life‐prolonging treatment for dying patients and appropriate opioid use may be associated with achievement of a good death in Japan. Copyright © 2007 John Wiley & Sons, Ltd.     

IPOS Sutherland Memorial Lecture: psycho-oncology and health care research

Remarkable changes of health-care systems, increasing costs of health care and of social inequality in modern societies, an aging population and the increase of chronic illnesses such as cancer implicate various future challenges for the provision of health care. Health-care research aims to improve the effectiveness and efficiency of patient-oriented services involving the evaluation of innovative treatment approaches and settings. It deals with the patients' path through different areas of health-care systems in order to identify significant factors for the provision of quality assurance of structures and resources concerning treatments, processes and health outcomes. Health-care research focusses on three main topics that play an important role for quality management: (1) the admission to health-care services and assessment strategies including indication, utilization and specificity of settings and target groups; (2) the treatment process including the implementation, standardization and flexibility of services and dose-effect relationship of interventions; (3) health-care outcome including effectiveness and efficiency of interventions and services, the cost-benefit relationship and the transfer from research to health-care practice. Given the objectives of health-care research, the topics of health-care research in psychosocial care for cancer patients include the study of structural conditions of psycho-oncological services, the epidemiology of distress and mental disorders and the subjective need of psycho-oncological support in cancer patients, the improvement of psycho-oncological measures and assessment strategies in daily treatment, the study of psycho-oncological interventions under routine conditions, and quality assurance. Requirements of future health-care research and developments of psycho-oncology including aspects of orientation, strategies, health-care equity, and resources are discussed.     

Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer

BACKGROUND:

Receipt of chemotherapy at the end of life (EOL) is considered an indicator of poor quality of care for medical oncology. The objective of this study was to characterize the use of radiotherapy (RT) in patients with nonsmall cell lung cancer (NSCLC) during the same period.

METHODS:

Treatment characteristics of patients with incurable NSCLC who received RT at the EOL, defined as within 14 days of death, were analyzed from the National Comprehensive Cancer Network NSCLC Outcomes Database.

RESULTS:

Among 1098 patients who died, 10% had received EOL RT. Patients who did and did not receive EOL RT were similar in terms of sex, race, comorbid disease, and Eastern Cooperative Oncology Group performance status. On multivariable logistic regression analysis, independent predictors of receiving EOL RT included stage IV disease (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.09‐3.83) or multiorgan involvement (OR, 1.75; 95% CI, 1.08‐2.84) at diagnosis, age <65 years at diagnosis (OR, 1.85; 95% CI, 1.21‐2.83), and treating institution (OR, 1.24‐5.94; P = .02). Nearly 50% of EOL RT recipients did not complete it, most commonly because of death or patient preference.

CONCLUSIONS:

In general, EOL RT was received infrequently, was delivered more commonly to younger patients with more advanced disease, and often was not completed as planned. There also was considerable variation in its use among National Comprehensive Cancer Network institutions. Next steps include expanding this research to other cancers and settings and investigating the clinical benefit of such treatment. Cancer 2012. © 2012 American Cancer Society.     

Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward

BACKGROUND.

Acute palliative care units (APCUs) are gaining popularity in tertiary care centers. In this study, the authors examined the impact of opening an APCU on administrative outcomes for a general oncology ward (GOW) at a comprehensive cancer center.

METHODS.

The GOW database was reviewed for 3 periods: June 2000 through May 2002 (before the APCU opened), June 2002 through May 2004 (transitional period, including APCU opening in a temporary location), and June 2004 through May 2006 (after opening of the APCU). Data were extracted on demographics, reasons for admission, admission type, waiting time for admission, length of stay (LOS), overstay (>2 days over expected LOS), death rate, and discharge destination. Linear regression analysis and the Cochran‐Armitage test were used for data analysis.

RESULTS.

There were 5340 admissions: The median patient age was 60 years, and 55% of patients were women. The most common primary cancers were head and neck (22%), gynecologic (21%), gastrointestinal (13%), and lung (12%). There were significant trends on the GOW in decreased admissions for palliative care (12.2%, 9.6%, and 7.9%, respectively, for the 3 periods; P < .0001), fewer inpatient deaths (11.4%, 8.6%, and 6.1%, respectively; P < .0001), and fewer patients with prolonged waits for a bed on a palliative care unit (3.4%, 3%, and 1.7%, respectively; P = .002). Admissions increased for interventions (10.4%, 17.3%, and 22.5%, respectively, for the 3 periods; P < .0001) and for chemotherapy (6.8%, 6.6%, and 9.7%, respectively; P = .001).

CONCLUSIONS.

After the opening of an APCU at the authors' cancer center, the GOW experienced a decrease in administrative endpoints related to palliative and end‐of‐life care and an increase in endpoints related to cancer‐directed interventions. Prospective studies with clinical endpoints will be required to determine whether this specialization of inpatient care improves quality of life, quality of death, and psychosocial well being. Cancer 2008. © 2008 American Cancer Society.