Processes of Discontinuing Chemotherapy for Metastatic Non–Small-Cell Lung Cancer at the End of Life

Pirl, William F.; Greer, Joseph A.; Irwin, Kelly E.; Lennes, Inga T.; Jackson, Vicki A.; Park, Elyse R.; Fujisawa, Daisuke; Wright, Alexi A.; Temel, Jennifer S.

doi:10.1200/jop.2014.002428

Cited by 22 publications

(11 citation statements)

References 26 publications

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“…Administration of chemotherapy close to death usually represents poorly planned care. 28 It was encouraging to find that only 5% of our study population received chemotherapy within the last 4 weeks of life, however, this limited the potential to explore the impact of palliative care on late chemotherapy. Studies that have established an association between palliative care team involvement and lower rates of chemotherapy near the end of life have concluded that cessation of chemotherapy is due to palliative care involvement.…”

Section: Discussionmentioning

confidence: 93%

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study

et al. 2018

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ObjectivesThis study aimed to establish the association between timing and provision of palliative care (PC) and quality of end-of-life care indicators in a population of patients dying of cancer.SettingThis study uses linked cancer patient data from the National Cancer Registry, the electronic medical record system used in primary care (SystmOne) and the electronic medical record system used within a specialist regional cancer centre. The population resided in a single city in Northern England.ParticipantsRetrospective data from 2479 adult cancer decedents who died between January 2010 and February 2012 were registered with a primary care provider using the SystmOne electronic health record system, and cancer was certified as a cause of death, were included in the study.ResultsLinkage yielded data on 2479 cancer decedents, with 64.5% who received at least one PC event. Decedents who received PC were significantly more likely to die in a hospice (39.4% vs 14.5%, P<0.005) and less likely to die in hospital (23.3% vs 40.1%, P<0.05), and were more likely to receive an opioid (53% vs 25.2%, P<0.001). PC initiated more than 2 weeks before death was associated with avoiding a hospital death (≥2 weeks, P<0.001), more than 4 weeks before death was associated with avoiding emergency hospital admissions and increased access to an opioid (≥4 weeks, P<0.001), and more than 33 weeks before death was associated with avoiding late chemotherapy (≥33 weeks, no chemotherapy P=0.019, chemotherapy over 4 weeks P=0.007).ConclusionFor decedents with advanced cancer, access to PC and longer duration of PC were significantly associated with better end-of-life quality indicators.

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Section: Discussionmentioning

confidence: 93%

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study

et al. 2018

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“…This qualitative approach to characterize processes involved in medical decision-making based on a medical record review has been used previously. 17 …”

Section: Methodsmentioning

confidence: 99%

Processes of code status transitions in hospitalized patients with advanced cancer

El‐Jawahri

Lau-Min

Nipp

et al. 2017

Cancer

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Background Although hospitalized patients with advanced cancer have low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to Do-Not-Resuscitate (DNR) are unknown. Methods We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes leading to code status order transitions from full code to DNR. Results We reviewed 1047 hospitalizations among 728 patients. Admitting clinicians did not address code status in 53.0% of hospitalizations resulting in code status orders of ‘presumed full’. 275 patients (26.3%) transitioned from full code to DNR and 48.7% (134/275) of those had an order of ‘presumed full’ upon admission but upon further clarification, the patients expressed that they had wished to be DNR prior to the hospitalization. We identified three additional processes leading to order transition from full code to DNR: acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared to discontinuing therapy and education, transitions due to acute clinical deterioration were associated with less patient involvement (P=0.002), shorter time to death (P<0.001), and higher likelihood of inpatient death (P=0.005). Conclusions Half of code status order changes among hospitalized patients with advanced cancer were due to full code orders in patients who had a preference for DNR prior to hospitalization. Transitions due to acute clinical deterioration were associated with less patient engagement and higher likelihood of inpatient death.

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“…A ggressive end-of-life (EOL) care is prevalent for persons with advanced cancer. 1 In a recent study of patients with stage IV lung and colorectal cancer, 22% received chemotherapy in the last month of life despite knowing that treatment was unlikely to cure them. 2 Aggressive treatment at the EOL is also associated with poorer quality of life.…”

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confidence: 99%

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

et al. 2019

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IMPORTANCE Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans’ end-of-life care is unknown. OBJECTIVE To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. DESIGN, SETTING, AND PARTICIPANTS A modified difference-in-difference study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non–small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. EXPOSURES Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. MAIN OUTCOMES AND MEASURES Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. RESULTS Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67–3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53–0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62–0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, −$358 to −$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. CONCLUSIONS AND RELEVANCE Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

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Processes of Discontinuing Chemotherapy for Metastatic Non–Small-Cell Lung Cancer at the End of Life

Cited by 22 publications

References 26 publications

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study

Processes of code status transitions in hospitalized patients with advanced cancer

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

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