Referral timing of in-hospital cancer deaths to palliative care in a Saudi tertiary care hospital

Abstract

Introduction: Late referral of advanced cancer patients to palliative care adversely affects their end-of-life care. We conducted this study to determine the referral timing of in-hospital cancer deaths to palliative care in a Saudi tertiary care hospital.

Subjects and methods: A retrospective review of cancer referrals to palliative care during a 4-year period who eventually died in-hospital. The effect of different factors on referral timing was studied.

Results: From 1567 referrals, 887 (56.6%) were eligible. Referral during the last week of life occurred in 28% of cases. The median survival from the first referral was 19 days (95% CI, 16–22). In multivariate analysis, the survival differed significantly according to the referring specialty and the setting of referral (P = 0.002, and < 0.001; respectively). The survival was shorter for patients referred from the medical, haematology and paediatric oncology specialties and for those referred in the emergency room or while in-patients.

Conclusions: Referral of in-hospital cancer deaths to palliative care occurs late in our setting and many patients are referred when death is imminent. The identification of factors related to this late referral attitude may be helpful in future improvement of end-of-life cancer care. Further research is warranted to investigate other reasons that may lead to late referral and to find ways to improve referral timing.     

Quality of end-of-life treatment for cancer patients in general wards and the palliative care unit at a regional cancer center in Japan: a retrospective chart review

Goals In Japan, most cancer patients die in the hospital. The aim of this study was to assess the quality of end-of-life treatment for dying cancer patients in general wards and palliative care unit (PCU). Materials and methods A retrospective chart review study was conducted. The following data on cancer patients who died in general wards (N = 104) and PCU (N = 201) at a regional cancer center were collected: do-not-resuscitate (DNR) decisions, treatments in the last 48 h of life, and aggressiveness of cancer care for dying patients. Main results DNR orders were documented for most patients (94% in general wards, 98% in PCU, p = 0.067) and families usually consented (97%, 97%, p = 0.307). Comparison of general wards with PCU showed that, in the last 48 h of life, significantly more patients in general wards received life-sustaining treatment (resuscitation, 3.8%, 0%, p = 0.001; mechanical ventilation, 4.8%, 0%, p = 0.004), large volume hydration (>1,000 ml/day, 67%, 10%, p < 0.001) with continuous administration (83%, 5%, p = 0.002) and fewer palliative care drugs (strong opioids, 68%, 92%, p < 0.001; corticosteroids, 49%, 70%, p < 0.001; nonsteroidal anti-inflammatory drugs, 34%, 85%, p < 0.001). Regarding aggressiveness of cancer care, patients received a new chemotherapy regimen within 30 days of death (3.0%), chemotherapy within 14 days of death (4.3%), and intensive care unit admission in the last month of life (3.3%). Conclusion We found that families, not patients, consented to DNR, and life-sustaining treatments were appropriately withheld; however, patients on general wards received excessive hydration, and the use of palliative care drugs could be improved. Application of our findings can be used to improve clinical care in general wards.     

Quality of end-of-life care for patients with metastatic non-small-cell lung cancer in general wards and palliative care units in Japan

Purpose  

Patients with lung cancer in Japan often receive aggressive care near the end of life and die in an acute care hospital. We describe the differences in end-of-life care for metastatic non-small-cell lung cancer (NSCLC) patients between general wards and a palliative care unit (PCU).     

Indicators of poor quality end-of-life cancer care in Ontario

This study measures the proportion of cancer patients in Ontario, Canada, with intensive care unit (ICU) admissions, emergency room (ER) visits, or chemotherapy in the last two weeks of life. We used the Ontario Cancer Registry to identify a cohort of cancer patients who died in 2001. These cases were then linked to administrative sources of data to measure each indicator, and to describe the associated clinical and health service factors. In the cohort, 27% had at least one ER visit and 5% had an ICU visit in the last two weeks of life. Of those who received chemotherapy in the last six months, 16% received chemotherapy in the last two weeks of life. Receiving a home care visit in the last six months of life, or a physician house call or a palliative care assessment in the last two weeks of life was consistently associated with decreased odds of each of the indicators. Our results indicate that a significant proportion of Ontario cancer patients have indicators of poor quality end-of-life care. Certain health care factors may influence these indicators.     

Intensity of Cancer Care Near the End of Life at a Tertiary Care Cancer Center in Jordan

ContextChemotherapy use in the last month of life is an indicator of poor quality of end-of-life care.ObjectivesWe assessed the frequency of chemotherapy use at the end of life at our comprehensive cancer center in Jordan and identified the factors associated with chemotherapy use.MethodsWe conducted a retrospective chart review to examine the use of chemotherapy in the last 30 days and 14 days of life in consecutive adult patients with cancer seen at King Hussein Cancer Center (KHCC) who died between January 1, 2010, and December 31, 2012. We collected data on patient and disease characteristics, palliative care referral, and end-of-life care outcome indicators.ResultsAmong the 1714 decedents, 310 (18.1%) had chemotherapy use in the last 30 days and 142 (8.3%) in the last 14 days of life. Over half (910; 53.1%) had a palliative care referral. Chemotherapy use in the last 30 and 14 days of life were associated with younger age (odds ratio [OR] 0.99/yr, P = 0.01, and OR 0.99/yr, P = 0.01, respectively) and hematological malignances (OR 1.98, P < 0.001, and OR 2.85, P < 0.001, respectively). Palliative care referral was significantly associated with decreased use of chemotherapy in the last 30 (OR 0.30, P < 0.001) and 14 (OR 0.15, P < 0.001) days of life.ConclusionsA sizable minority of patients with cancer at KHCC received chemotherapy at the end of life. Younger patients and those with hematological malignancies were more likely to receive chemotherapy, whereas those referred to palliative care were significantly less likely to receive chemotherapy at the end of life.     

Taking care of terminally-ill patients at home - the economic perspective revisited

End-of-life care can be delivered in a variety of settings, whereby the majority of terminally-ill cancer patients prefer to die at home. The aim of our study is to evaluate health services utilisation during the last year of life, and to compare terminally ill patients who have received home-specialised palliative care services (HSPCS) with patients who died receiving home non-specialised palliative care services. The study included 120 and 515 patients, respectively, who died between 1999-2000. Age and gender distribution were similar in both groups. During the last year of life, mean health services cost per person among the HSPCS group was lower by more then 30% (P < 0.005). The median cost per patient was as low as one-fifth in the last month. Men and the older age group of 65 and above, cost significantly less compared with women and younger patients, respectively, regardless of provider setting. The main differences in health services utilisation were in hospitalisations and oncology treatments (P < 0.01 and P < 0.05, respectively).     

The use of palliative care services associated with better dying circumstances. Results from an epidemiological population-based study in the brussels metropolitan region

Context

There is some consensus that a “good death” is one which occurs at home, in the presence of loved ones, and is free of distress. Involvement of palliative care services is assumed to improve these circumstances.

Objectives

This population-based study describes characteristics of the end of life of patients dying in Brussels and examines their associations with the involvement of palliative care services.

Methods

In 2007, an anonymous large-scale mortality follow-back survey was conducted in Brussels by mailing questionnaires regarding end-of-life care and characteristics to the attending physicians of a representative sample of 1961 deaths.

Results

Response rate was 41% (n = 701). Of all deaths, 59% were nonsudden. Of these, 12% took place at home. For 27%, the attending physician was informed about the patient’s preferred place of death. When the preference to die at home was known, 66% died at home. At the moment of death, in 47% of nonsudden deaths, loved ones were present. In a quarter of deaths, palliative care services were involved. Involvement with palliative care services was more likely for cancer patients than noncancer patients and was associated with the attending physicians more often being informed about the preferred place of death, with patients more often dying at home, with loved ones more often being present, and with a better feeling of well-being on the last day.

Conclusion

Overall, circumstances at the very end of life are suboptimal in Brussels. This study provides a case for stronger involvement of palliative care as a focal point for policies to improve end-of-life circumstances in a metropolitan area such as Brussels.     

Targeted therapy at the end of life in advanced cancer patients

Abstract Objective: We describe the use of systemic therapy in advanced cancer patients admitted to an acute care hospital, with a focus on targeted therapy. We aim to spotlight the utilization of targeted agents in the last months of life. Methods: Adult patients (N=252) with advanced solid tumors who died as inpatients in the National University Hospital, Singapore, were included in this retrospective study. Patients' demographic and clinical data were extracted from hospital records. Information on systemic therapy was extracted from the time of diagnosis and all other data limited to the last three months before death. Results: 187 adult patients received palliative systemic therapy from the time of diagnosis, of which 125 (66.8%) received it within three months of death. Of patients receiving only nontargeted systemic treatment (n=106), 60 (56.6%) and 26 (24.5%) received it within three months and one month of death respectively. Comparatively, 81 patients received palliative targeted systemic therapy, of which 65 (80.3%) and 40 (49.4%) had treatment within three months and one month of death respectively (p=0.001 and p<0.001). Targeted therapy was first initiated in the last three months of life in 38 patients. Oral agents targeting epidermal growth factor receptor (lung cancer patients) and vascular endothelial growth factor receptor (non-lung cancer patients) pathways were commonly employed. Lung cancer patients were more likely to have targeted therapy as their last line of systemic therapy: 26/54 lung cancer patients compared with 29/133 non-lung cancer patients (48.1% versus 21.8%, p<0.001). Conclusions: Targeted therapy is used in more than half of patients who received systemic therapy within three months of death. The degree to which these agents are being utilized near the end of life suggests the need to reexamine the risk/benefit profile of targeted therapy for this population, and the decision-making process around their use.     

The association of physical and psychological symptom burden with time to death among palliative cancer outpatients

Previous studies have reported on the symptom burden of cancer inpatients, but outpatient studies have been few and have not examined the association of symptoms with time to death (TTD). Cancer patients seen in an oncology palliative care clinic from January 2005 to June 2006 and who subsequently died were identified from a palliative care database. Data from the last outpatient Edmonton Symptom Assessment Scale (ESAS) score completed in clinic were analyzed among patients who were followed during the last four months of life. Multiple linear regression analyses with Bonferroni adjustment were used to determine the association of ESAS total symptom distress score (TSDS), physical subscore (PHS), psychological subscore (PSS), and individual symptom scores with demographic parameters, disease characteristics, and TTD. Data from 198 patients were analyzed. All had stage IV cancer, the median age was 65, and 55% were men. There was no significant association between symptom burden and age, gender, or cancer site. TTD was significantly associated with TSDS (P=0.001) and PHS (P=0.001) but not with PSS (P=1.0). Individual symptoms most strongly associated with TTD were lack of appetite (P=0.001), drowsiness (P=0.006), dyspnea (P=0.009), and fatigue (P=0.01). There was no significant association between TTD and anxiety (P=1.0) or depression (P=1.0). Lack of appetite, drowsiness, dyspnea and fatigue represent a cluster of symptoms that tend to intensify at the end of life. The lack of intensification of psychological symptoms in relation to time to death is striking and needs to be further investigated using specific validated measures for depression and anxiety.     

Hydration management at the end of life

The management of parenteral hydration at the end of life remains controversial. The debate centers on whether and/or how often patients should be hydrated, the volume of hydration received, and the benefit verses side effects of parenteral hydration. In order to clarify the routine practice of physicians involved in the end-of-life care in Edmonton, Alberta, Canada, we investigated the routine management of hydration by attending physicians caring for patients dying in a palliative care unit (PCU) at Norwood Capital Care, and in acute care wards at the Royal Alexandra Hospital (RAH) both while receiving and while not receiving consult advice from the Palliative Care Program. We conducted a retrospective chart review of 50 consecutive patients who died in each of the 3 sites included in the study. Data from the last 7 days prior to and including the date of death (day 0) was recorded. The majority of patients at all sites received hydration. The volume of hydration ordered in the Norwood PCU site was significantly different compared to both RAH groups on all days studied (p < 0.005). The RAH palliative care group showed a trend for lower hydration volumes compared to the RAH acute care group with significant differences on days 1 and 2 (p < 0.05). Throughout the week, for all of the hydrated patients in the Norwood PCU site, hypodermoclysis (HDC) was ordered; for nearly all of the hydrated patients in the RAH acute care group, intravenous (IV) hydration was ordered; and for approximately one third of the hydrated RAH palliative care consult group HDC was ordered, and for the remainder IV hydration was ordered. The RAH acute care group represented the largest percentage of hydrated patients receiving diuretics while the Norwood hospice site represented the lowest. The data raise the possibility that more patients in the RAH acute care group were overhydrated and may have developed symptoms such as edema, ascites, and respiratory distress. This study suggests that hydration at the end of life is managed differently in different settings of care and highlights areas for education to improve management.     

The last 3 months of life of cancer patients: Medical aspects and role of home-care services in southern Switzerland

The clinical data on terminal cancer patients who have died since the establishment of a program of collaboration between community services and the cancer center of Canton of Ticino, southern Switzerland, were retrospectively analyzed to describe the characteristics of patients seen and the effect on them of a home-care program coordinated by the cancer center. The home-care program is based on five geographically grouped community-based domiciliary services, with the addition of one nurse responsible for coordination and one physician from the oncology center. Selection criteria for participation in the home-care program are defined. The main outcome measures were: number of hospitalizations and median hospital stay during the last 3 months of life; reasons for and median length of last hospitalization; place of death of patients who had home care and those who did not. In the group of 993 patients analyzed, the median contact time with the cancer center was 9.5 months (10th percentile: 1 month, 90th percentile: 71 months); the most frequent neoplasm was lung cancer (22%) with the briefest contact time (7.5 months; 10th percentile: 1 month; 90th percentile: 21 months); 13.5% of patients were never hospitalized; half of the patients had a total hospital stay of 24 days or longer and 23% died at home. The sociodemographic and medical characteristics of home-care users were similar to those of the home-care nonusers and to those of the overall group. In the group of home-care users (32% of the total) 22% were never hospitalized, half of the patients had a total hospital stay of 17 days or longer, and 43.5% of them died at home. These values were significantly different (P<0.001) from those reported in the group of home-care non-users. Palliative care, provided at home through community-based domiciliary services, is associated with less frequent and shorter hospitalizations in the last 3 months of life. Medical oncology and palliative treatments should be mutually complementary to improve patients care. Cancer centers should be involved in the planning and coordination of supportive-care domiciliary services.     

Involvement of general practitioners in palliative cancer care: a qualitative study

Purpose

General practitioners play an important role in palliative care for cancer patients. The intensity of care and its medical complexity make palliative care a demanding task for general practitioners. This study explored general practitioners' perceptions of their involvement in palliative cancer care and the constraints they confront.

Methods

We conducted semi-structured interviews with 13 German general practitioners. Recruitment occurred by means of purposeful sampling to secure maximum heterogeneity. The interviews were electronically recorded, transcribed, and then analyzed using qualitative content analysis according to Mayring.

Results

A number of themes were identified. General practitioners describe being intensely involved in the final phase of their patients' lives. When providing home-based end-of-life care to cancer patients, general practitioners become aware of the limitations in their medical skills and knowledge and their ability to provide round-the-clock care. They find it helpful and satisfying to collaborate with trusted care providers and seek to cooperate with specialized palliative care services for outpatients.

Conclusions

The substantial involvement of general practitioners in end-of-life care for cancer patients pushes them to their limits because of the major time commitment required, and the need for special skills for which they have received no training. It will be a challenge to provide general practitioners with the structural and personal support they need to provide home-based palliative care for their cancer patients at end of life.     

Differences in supporting families of dementia patients and cancer patients: a palliative perspective

OBJECTIVES: To investigate what staff working in close contact with patients perceive as good support of families in dementia care as compared with support of families in palliative cancer care. DESIGN AND SUBJECTS: During four national courses on dementia care and one national course on palliative cancer care, 316 and 121 participants, respectively, responded to an open-ended question: In your experience, what are the two most important measures for supporting families of dementia patients/severely ill cancer patients? Sixty-one items were coded and allocated into 10 main categories and analysed with both a qualitative and quantitative approach. RESULTS: The dominant items for both staff groups were to listen to the family member and to give information, although listening was significantly more often stressed in the palliative group (P < 0.001). The staff in dementia care stressed significantly more the importance to form support groups for families (P < 0.001), to offer respite care (P < 0.001), to educate families (P < 0.001) and to try to relieve the family's feeling of guilt (P < 0.001). In the palliative staff group, the importance of being available (P < 0.05), creating a sense of security (P < 0.001) and supporting the family after the patients death (P < 0.01) were significantly more focused on. DISCUSSION: The respondents from the dementia staff group and from the palliative cancer group stressed the importance of supporting family members. However, the type of support needed partly differs because of the different trajectories in dementia compared with severe cancer phases.     

Advance Care Planning and Dying in Nursing Homes in Flanders,Belgium: A Nationwide Survey

ContextIn Belgium, data on actual advance care planning (ACP) in nursing homes (NHs) are scarce.ObjectivesTo investigate the prevalence and characteristics of documented advance directives and physicians' orders for end-of-life care in NHs, and the authorization of a legal representative in relation to the residents' demographic and clinical characteristics and care received.MethodsThis was a retrospective cross-sectional study, including all NH residents deceased during September and October 2006 in all 594 NHs in Flanders, Belgium. Structured mail questionnaires about the resident's characteristics, hospital transfers, palliative care delivery, ACPs, and authorization of legal representatives were completed via the NH administrators and nurses involved in the care of the resident.ResultsAdministrators of 318 NHs (53.5%) reported 1303 deaths. Nurses provided information about 1240 (95.2%) of these deaths. At the end of life, NH residents often had dementia (65.2%) and were severely dependent (76.1%). Almost half (43.1%) had at least one hospital transfer during the last three months of life and two-thirds received palliative care. Half had an ACP, predominantly a physician's order and less often an advance directive. Having advance directives or physician's orders was associated with receiving palliative care. Residents with a physician's order more often died in the NH. Nine percent had an authorized legal representative.ConclusionPrevalence of ACPs and formal authorization of a legal representative was low among the deceased NH residents in Flanders, Belgium. There was a higher prevalence of physicians' orders, often established after the resident had lost capacity. Initiatives should be developed to stimulate more advance discussion on care options and making end-of-life decision with the residents while they retain capacity.     

Aggressiveness of End-of-Life Care for Patients With Colorectal Cancer in Alberta,Canada: 2006–2009

ContextNorth American studies have documented practice variations and deficiencies in end-of-life (EOL) cancer care, such as trends toward treating dying patients aggressively and disparities in access to palliative care or hospice services.ObjectivesTo assess the frequency of aggressive health care usage at the EOL and identify factors associated with receiving aggressive care among patients who died of colorectal cancer.MethodsData from the Alberta Cancer Registry, in/outpatient hospital records, and cancer electronic medical records were linked. Death in an acute care hospital, chemotherapy use in the last 14 days of life, more than one emergency room (ER) visit, more than one hospital admission, and any intensive care unit (ICU) admission in the last 30 days of life were used as indicators of aggressive care. Logistic regression was used to identify risk factors associated with each indicator.ResultsA total of 2074 patients were included: 50.1% died in an acute care hospital; 3.7% received chemotherapy in the last 14 days of life; and 12.5% had multiple ER visits, 9.5% had multiple hospitalizations, and 2.2% had an ICU admission during the last 30 days of life. Age had the strongest association with chemotherapy use. Geographical region of residence had the strongest association with multiple ER visits and hospitalizations and dying in an acute care hospital. Tumor stage and duration of disease were associated with the ICU admission.ConclusionThe percentage of patients who died in an acute care hospital is higher than the 17% U.S. benchmark. Other indicators of receiving aggressive EOL care are consistent with existing care quality benchmarks. The considerable regional variation, however, indicates potential for system improvements.     

End-of-Life Health Care Utilization Between Chronic Obstructive Pulmonary Disease and Lung Cancer Patients

Context

At the end of life, chronic obstructive pulmonary disease (COPD) and lung cancer (LC) patients exhibit similar symptoms; however, a large-scale study comparing end-of-life health care utilization between these two groups has not been conducted in East Asia.

Impact of availability of an inpatient hospice unit on the parent hospital's quality of palliative care for Taiwanese cancer decedents, 2001-2006

Context

Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals.

Objectives

To investigate the impact of an inpatient hospice unit on the parent hospital’s quality of palliative care.

Methods

This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001–2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend.

Results

Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit.

Conclusion

Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients’ characteristics.     

The healthcare needs of chronic obstructive pulmonary disease patients in the last year of life

Chronic obstructive pulmonary disease (COPD) causes almost as many deaths as lung cancer, yet evidence about the impact of COPD in the latter stages of illness is limited. We assessed the healthcare needs of COPD patients in the last year of life through a retrospective survey of the informants of 399 deaths from COPD in four London health authorities between January and May 2001. We assessed symptoms, day to day functioning, contact with health and social services, formal and informal help with personal care, information received and place of death. We obtained data on 209 (52%) deceased subjects (55% male), average age at death was 76.8 years. Based on the reports of informants of the deaths: 98% were breathless all the time or sometimes in the last year of life; other symptoms reported all the time or sometimes included fatigue or weakness (96%), low mood (77%) and pain (70%); breathlessness was partly relieved in over 50% of those treated; control of other symptoms was poor, with low mood relieved in 8% and no treatment for low mood received by 82% of sufferers; 41% left the house less than once a month or never; 47% were admitted to hospital at least twice in the last year of life; 51% received regular check-ups for their chest; 36% had check-ups by a hospital consultant; 35% saw their general practitioner (GP) less than once every three months or never; 63% knew they might die; 67% died in hospital. Patients who died from COPD lacked surveillance and received inadequate services from primary and secondary care in the year before they died. The absence of palliative care services highlights the need for research into appropriate models of care to address uncontrolled symptoms, information provision and end of life planning     

End-of-life care in hospitalized adults with complex congenital heart disease: care delayed, care denied

Adults with congenital heart disease represent a growing patient population. Notwithstanding dramatic improvements in survival and life expectancy over recent decades, many of these patients remain at risk of premature death from progressive heart disease and would benefit from the principles of palliative and end-of-life care. Data on end-of-life care in this patient group are, however, lacking. We report a retrospective study of 48 patients with congenital heart disease who died while admitted to our hospital (mean age at death 37 ± 14 years). We describe circumstances of death, end-of-life discussions, and the provision of end-of-life care. The majority of patients had complex congenital heart disease and were considered to be in the end stage of their disease. Despite this, only a minority of patients had documented end-of-life discussions prior to their terminal admission and most received continuing aggressive medical treatment up to their demise. Advanced palliative and end-of-life care strategies should be developed for and provided to this group of patients, with the dual aims of reduction of unwarranted therapies and enhancement of the quality of death and dying.