Objectives: Communication about end-of-life decisions is crucial. Although patients with metastatic spinal cord compression (MSCC) have a median survival time of 3 to 6 months, few data are available concerning the presence of advance directives and do-not-resuscitate (DNR) orders in this population. The objective of this study was to determine presence of advance directives and DNR order among patients with MSCC. Methods: We retrospectively reviewed data concerning advance directives for 88 consecutive patients with cancer who had MSCC and required rehabilitation consultation at The University of Texas M. D. Anderson Cancer Center from September 20, 2005 to August 29, 2008. We characterized the data using univariate descriptive statistics and used the Fisher exact test to find correlations. Results: The mean age of this patient population was 55 years (range, 24-81). Thirty patients (33%) were female. Twenty patients (23%) had a living will, 27 patients (31%) had health care proxies, and 10 patients (11%) had either out-of-hospital DNR order and=or dictated DNR note. The median survival time for these patients was 4.3 months. Conclusion: Despite strong evidence showing short survival times for MSCC patients, it seems many of these patients are not aware of the urgency to have an advance directive. This may be an indicator of delayed end-oflife palliative care and suboptimal doctor-patient communication. Using the catastrophic event of a diagnosis of MSCC to trigger communication and initiate palliative care may be beneficial to patients and their families.

Background Acute inpatient rehabilitation is often utilized by cancer patients to assist with discharge home and/or preparation for further treatment. Private insurance patients often require approval before transfer to acute inpatient rehabilitation. Objective To analyze the approval rate of private insurance carriers for acute inpatient cancer rehabilitation. Design Retrospective Analysis Setting Tertiary Referral Based Cancer Center Patients Ninety-six consecutive unique patients with private insurance who had acute inpatient rehabilitation authorization requests made between 4/1/2014 and 9/17/2014. Intervention Patient cases were assessed by a physiatrist, deemed clinically appropriate for acute inpatient rehabilitation, and submitted to private insurance payers for an approval request. Results Eighty seven percent (84/96) of requests for private insurance authorization for inpatient rehabilitation transfer were approved. Of the 96 cases, 14 (14.6%) cases were initially denied. Nine out of 96 (9.4%) progressed to a peer to peer appeal, of which only 2/9 (11.1%) resulted in approval for inpatient rehabilitation transfer (p=.222). The insurance carriers represented were Insurance A (46 patients, 48%), Insurance B (18 patients, 19%), Insurance C (12 patients, 13%), and Other Insurances (20, 21%). Two of 46 Insurance A requests were initially denied as compared to 7/18 for Insurance B, 0/12 for Insurance C, and 4/20 for Other Insurances (p=.001). Patients with Insurance B (p=.002, OR=14) and Other Insurances (p=.062, OR=5.50) were more likely to get denied inpatient rehabilitation approval compared to Insurance A. No significant difference between mean functional independence measure scores for approved and denied patients were found for transfers (p=.239) and mobility (p=.129) respectively. Conclusion Access to acute inpatient rehabilitation is unfortunately limited by insurers rather than clinical indicators. Future multi-center studies are needed. Universally accepted guidelines regarding inpatient rehabilitation criteria are needed.

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54 Background: Surgery in older adults is a physiologically stressful event associated with reduced functional capacity and decreased quality of life. Poor preoperative performance is linked to risk of postoperative complications and prolonged functional recovery. The goal of this study is to determine the efficacy of an independent, home-based exercise program in improving physical performance prior to cancer-related surgery. Methods: Retrospective study of 217 consecutive patients referred for comprehensive prehabilitation including physical medicine and rehabilitation physician and physical therapy visits prior to intended oncologic surgery. Physical performance was assessed at consultation (baseline) and at the preoperative follow up visit in physical therapy. Physical performance measures included Six-Minute Walk test (6MWT), Five Times Sit to Stand (5xSTS), hand grip strength (HGS), gait speed (GS), and Timed Up and Go (TUG). Results: Median (IQR) age was 71 (64,77). The most common primary cancer diagnoses were gastrointestinal (43%), genitourinary (15%), breast (9%), and sarcoma (7%). 144 of the 217 (66%) underwent surgery and of these, 75 (52%) completed preoperative functional measures during their physical therapy follow-up. For the entire cohort of 217 patients, baseline median (IQR) measures included: 6MWT distance was 357 (193.3, 420) meters, 5xSTS was 12 (9.1, 16.3) seconds, right HGS was 43.3 (30.0, 58.3) pounds, GS was 1.4 (1, 1.7) meters per second, and TUG was 8.6 (7.3, 12.2) seconds. There were similar baseline physical function results in the cohort who completed preoperative measures. During the preoperative period (from baseline to pre-surgery visit), there was significant improvement in the 6MWT ( P=0.003), 5xSTS ( P=0.000), and TUG ( P=0.027). There was no significant change in HGS or GS. Conclusions: At baseline, most patients had major functional impairment, especially decreased submaximal exercise capacity. With the independent, home-based exercise prehabilitation program, patients had significant improvement in physical performance. Prehabilitation should be further investigated in these patients.

V enous thromboembolism, which includes deep vein thrombosis and pulmonary embolus, is a life-threatening complication for hospitalised patients. Compared to the general population, cancer patients are at a fourfold increase in the frequency of venous thromboembolism, and as high as a sixfold increase during chemotherapy (Heit et al, 2000). Cancer-associated venous thromboembolism is prevalent, with the rate increasing by 28% from 1995 to 2003, with an overall venous thromboembolism incident rate of 4.1%, with 3.4% being deep vein thrombosis and 1.1% being pulmonary embolus, in a recent analysis of 1 000 000 hospitalised cancer patients (Khorana et al, 2007). These patients also have significantly worse chances of survival (Sørensen et al, 2000; Auer et al, 2012), suffering from higher rates of complications of bleeding and recurrent venous thromboembolism (Sørensen et al, 2000, Prandoni et al, 2002Khorana et al, 2007). The mortality rate for pulmonary embolus following a deep vein thrombosis ranges from 5% to 37% in untreated patients and is about 6% among patients treated after diagnosis with anticoagulation (Wilson and Murray, 2005).In a previous study by Ng et al (2017), it was reported that 5.2% of cancer patients were affected with venous thromboembolism during the course of rehabilitation. Patients who were found to have lower extremity oedema at admission (P=0.02) had Calf measurements screening for deep vein thrombosis in acute inpatient cancer rehabilitation