Impact of timing and setting of palliative care referral on quality of end‐of‐life care in cancer patients

Abstract

Background Limited data is available on how the timing and setting of palliative care referral can affect end-of-life care. In this retrospective cohort study, we examined how the timing and setting of palliative care (PC) referral were associated with the quality of end-of-life care. Methods All adult patients residing in the Houston area who died of advanced cancer between 9/1/2009 and 2/28/2010 and had a PC consultation were included. We retrieved data on PC referral and quality of end-of-life care indicators. Results Among 366 decedents, 120 (33%) had early PC referral (>3 months before death) and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs. 68%, P<0.001), hospitalizations (48% vs. 81%, P<0.003), and hospital deaths (17% vs. 31%, P=0.004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs. 68%, P<0.001), hospital admissions (52% vs. 86%, P<0.001), hospital deaths (18% vs. 34%, P=0.001) and intensive care unit admissions (4% vs. 14%, P=0.001). In multivariate analysis, outpatient PC referral (odds ratio [OR]=0.42, 95% confidence interval [CI] 0.28-0.66; P<0.001) was independently associated with less aggressive end-of-life care. Male sex (OR=1.63, 95%CI 1.06-2.50; P=0.03) and hematologic malignancy (OR=2.57, 95%CI 1.18-5.59; P=0.02) were associated with more aggressive end-of-life care. Conclusion Patients referred to outpatient PC had improved end-of-life care compared to inpatient PC. Our findings support the need to increase the availability of PC clinics and to streamline the process of early referral.

Impact of Oncologists’ Attitudes Toward End-of-Life Care on Patients’ Access to Palliative Care

“…We recently reported that early specialist palliative care referral was significantly associated with lower rates of emergency room visits, hospitalization, and intensive care unit admissions in the last 30 days of life, but not the rates of chemotherapy or targeted therapy use [19]. Taken together, these results suggest that the decision-making process regarding chemotherapy use at the EOL might be a separate construct from the delivery of palliative care.…”

Indicators of integration of oncology and palliative care programs: an international consensus

“…Recognizing the significant supportive care needs among cancer patients and the role that palliative care plays in addressing these needs [1][2][3][4], multiple national and international professional organizations have called for increased integration of oncology and palliative care [5][6][7][8]. Since 2004, the European Society for Medical Oncology (EMSO) offered an incentive program of 'ESMO designated centers of integrated oncology and palliative care' based on 13 criteria that focused on the palliative carerelated processes, education, and research; however, these criteria did not explicitly include formal clinical structures [6].…”

Early Palliative Care and Its Role in Oncology: A Qualitative Study

“…Of these, the model that has received the greatest attention and endorsement, in particular, for cancer centers, is simultaneous care by specialized palliative care in an outpatient setting [13,15,16]. This model was used in two randomized controlled trials (RCTs) demonstrating the benefits of EPC and was also supported by the results of nonrandomized prospective and retrospective studies [17][18][19]. Although this model has been examined qualitatively by a review of the electronic medical records of patients receiving EPC [20] and by interviewing oncologists and palliative care physicians [21,22], the opinions of patients and caregivers regarding this model of care have not been sought.…”