Interventions to reduce aggressive care at end of life among patients with cancer: a systematic review

Abedini, Nauzley C.; Hechtman, Rachel K.; Singh, Achintya D.; Khateeb, Rafina; Mann, Jason; Townsend, Whitney; Chopra, Vineet

doi:10.1016/s1470-2045(19)30496-6

Cited by 37 publications

(32 citation statements)

References 55 publications

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“…Finally, we could not determine the intention behind the procedures received, the patient's preferences in receiving them, or the context for the racial disparities we observed. However, the markers for aggressive care that we used are well established as indicative of the quality of end‐of‐life care and were designed for measurement from claims data 4,5,39 . Future studies delving into the mechanisms behind these findings are needed.…”

Section: Discussionmentioning

confidence: 99%

Trends and racial disparities in aggressive end‐of‐life care for a national sample of women with ovarian cancer

Mullins

Ruterbusch

Clarke

et al. 2021

Cancer

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BACKGROUND The clinical landscape has moved toward less aggressive end‐of‐life care for women with ovarian cancer. However, whether there has been a decline in the use of aggressive end‐of‐life services is unknown. The authors evaluated current national trends and racial disparities in end‐of‐life care among women with ovarian cancer using the Surveillance, Epidemiology, and End Results‐Medicare–linked data set. METHODS In total, 7756 Medicare beneficiaries aged >66 years with ovarian cancer who died between 2007 and 2016 were identified. The authors examined trends and racial disparities in late hospice or no hospice use, >1 emergency department (ED) visit, intensive care unit admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life‐extending procedures using multivariable logistic regression. RESULTS The median hospice length of stay did not change over time; however, women were increasingly admitted to the intensive care unit and had multiple ED visits in the last month of life (P < .001). Not enrolling in hospice at the end of life and terminal hospitalizations decreased over time (P < .001). Non‐White women were more likely to receive aggressive end‐of‐life care, particularly for hospital‐related utilization and life‐extending procedures, whereas non‐Hispanic Black women were more likely to have >1 ED visit (odds ratio, 2.04; 95% CI, 1.57‐2.64) or life‐extending procedures (odds ratio, 1.89; 95% CI, 1.45‐2.48) compared with non‐Hispanic White women. CONCLUSIONS Despite clinical guidelines and increasing emphasis on reducing aggressive end‐of‐life care, the use of aggressive end‐of‐life care for women with ovarian cancer persists, and care is most aggressive for non‐White women.

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Section: Discussionmentioning

confidence: 99%

Trends and racial disparities in aggressive end‐of‐life care for a national sample of women with ovarian cancer

Mullins

Ruterbusch

Clarke

et al. 2021

Cancer

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“…The decision to proceed with aggressive care following IHCA can be life-saving but may also cause unnecessary pain and increase costs associated with end-of-life treatment [ 30 ]. In a recent systemic review, a documented discussion with a healthcare provider was the only intervention shown to reduce aggressive end-of-life care in cancer patients, emphasizing the important role of such interactions [ 31 ]. This study identified high-yield factors associated with post-CPR survival based upon a large nationally representative database.…”

Section: Discussionmentioning

confidence: 99%

A simple ABCD score to stratify patients with respect to the probability of survival following in-hospital cardiopulmonary resuscitation

Gibson

2021

Journal of Community Hospital Internal Medicine Perspectives

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Background: Cardiopulmonary resuscitation (CPR) is occurring more frequently at community hospitals but most patients undergoing CPR do not survive to discharge. Tools to predict CPR survival can be improved by the identification of high-yield clinical indicators. Objective: To identify variables associated with survival to discharge following in-hospital cardiac arrest. Methods: Retrospective cohort study of 463,530 hospital admissions from the Nationwide Inpatient Sample (2012)(2013)(2014)(2015)(2016). The analysis includes adults (age ≥50) who underwent inhospital CPR at US community hospitals. Results: Overall survival to discharge was 29.8% (95% CI: 29.5-30.1%). Age was the strongest predictor of survival and had greater prognostic value than the Charlson comorbidity index. Obesity was associated with improved survival (35.9%, 95% CI: 35.1-36.7%), whereas underweight patients had decreased survival (24.0%, 95% CI: 22.2-25.7%). Acute indicators of poor survival included hyperkalemia, hypercalcemia, and sepsis. We generated an ABCD index based upon four high-yield variables (age, body habitus, comorbidity, day of hospital admission). An ABCD score of 2 or less was a sensitive but non-specific predictor of post-CPR survival (96.8% sensitivity, 95% CI: 96.6-97.0), and those with extreme scores differed 3.8-fold with respect to post-CPR survival probability (46.0% versus 12.1%). Conclusion: Age is the strongest predictor of post-CPR survival, but body habitus is also an important indicator that may currently be underutilized. Our results support improved post-CPR survival of obese patients, consistent with an 'obesity paradox'. The ABCD score provides an efficient means of risk-stratifying patients and can be calculated in less than 1 minute.

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“…Specifically, two recent systematic reviews show that proactively initiated, structured communication (e.g. shared-decision making featuring discussions about treatment near to death between patients and physicians) may reduce the frequency of AOC and decision regret in patients (48,49). A recent study suggests that, for caregivers, comparable effects are achieved by involving them regularly in discussions about treatment at end-of-life of cancer patients (50).…”

Section: Comparison With Prior Workmentioning

confidence: 99%

Aggressiveness of Care at the End-of-Life in Cancer Patients and Its Association With Psychosocial Functioning in Bereaved Caregivers

et al. 2021

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Study Registrationhttps://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022837,DRKS00022837.BackgroundIntensified oncological treatment for advanced cancer patients at the end-of-life has been specified as aggressiveness of care (AOC) and increased over the past decades. The aims of this study were to 1) determine the frequency of AOC in Central Europe, and 2) investigate differences in mental health outcomes in bereaved caregivers depending on whether the decedent had experienced AOC or not.Materials and methodsWe conducted a cross-sectional study in a large tertiary comprehensive cancer care center in Germany. Bereaved caregivers provided information about (a) treatment within the last month of life of the deceased cancer patient and (b) their own mental health status, i.e., decision regret, complicated grief, depression, and anxiety. After multiple imputation of missing data, differences in mental health outcomes between AOC-caregivers and non-AOC-caregivers were analyzed in a multivariate analysis of variances.ResultsWe enrolled 298 bereaved caregivers of deceased cancer patients. AOC occurred in 30.9% of all patients. In their last month of life, 20.0% of all patients started a new chemotherapy regimen, and 13.8% received ICU-treatment. We found differences in mental health outcomes between bereaved AOC- and non-AOC-caregivers. Bereaved AOC caregivers experienced significantly more decision regret compared to non-AOC caregivers (Cohen’s d = 0.49, 95% CI [0.23, 0.76]).ConclusionAOC occurs frequently in European health care and is associated with poorer mental health outcomes in bereaved caregivers. Future cohort studies should substantiate these findings and explore specific trajectories related to AOC. Notwithstanding, shared-decision making at end-of-life should increasingly account for both patients’ and caregivers’ preferences.

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Interventions to reduce aggressive care at end of life among patients with cancer: a systematic review

Cited by 37 publications

References 55 publications

Trends and racial disparities in aggressive end‐of‐life care for a national sample of women with ovarian cancer

Trends and racial disparities in aggressive end‐of‐life care for a national sample of women with ovarian cancer

A simple ABCD score to stratify patients with respect to the probability of survival following in-hospital cardiopulmonary resuscitation

Aggressiveness of Care at the End-of-Life in Cancer Patients and Its Association With Psychosocial Functioning in Bereaved Caregivers

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