When does early palliative care influence aggressive care at the end of life?

Abstract

BackgroundEarly palliative care improves patient quality of life and in uences cancer care. The time frame of early has not been established. Eight quality measures re ect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018 through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL). MethodsPatients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30 days, 60-90 days, and greater than 90 days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with con dence intervals (CI) was reported as a measure of effect size. A p-value </= 0.05 was considered signi cant. Results1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). 71% had a palliative care consult, 26% completed AD, 888 (51.4%) had at least one indicator of ACEOL. AD completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64-0.99). Palliative care was associated with a greater risk of ACEOL at 30 days (OR 5.32,) and between 30 and 90 days (OR 1.39,95% CI 1.07-1.80), but dramatically reduced ACEOL at > 90 days (OR 0.46,95% CI 0.38-0.57).The most common indicator of ACEOL was new chemotherapy within 30 days of death, in 571 of 888 (64%) of patients experiencing ACEOL. DiscussionAD reduce ACEOL and often re ect goals of care and end-of-life discussions in the transition of care away from tumor directed therapy. Palliative care paradoxically in our experience is associated with greater ACEOL in the rst 90 days since consultation occurs late in the course of illness and the focus is on crisis management in patients who are frequently utilizing the health care system. If palliative care consultation occurs greater than 90 days before death, there is the opportunity for both aggressive symptom management and end of life discussions which may in uence aggressive care at the end of life.

The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs

“…56,57 Completed ADs reduce chemotherapy utilization within 30 days of death and ICU admissions in our experience. 58 However, completed ADs in this study did not reduce ICU costs despite reduced utilization. The difference likely reflects variability in ICU costs.…”

Prevalence of aggressive care among patients with cancer near the end of life: a systematic review and meta-analysis

“… 30 Palliative care can alleviate some aspects of aggressive EOL care, however, if patients are to fully benefit from it, they need to be referred early in the disease trajectory and ideally upon the diagnosis of any incurable cancer. 31 , 32 , 33 , 34 , 35 , 36 , 37 Despite being identified as a facilitator for the basic human right to death with dignity, access to palliative care for millions of individuals in need, especially in LMICs, continues to be limited or even absent. 38 , 39 Lack of available and accessible interventions that reduce aggressive care such as palliative care services may in turn exaggerates aggressive care near patients’ EOL, making it a vicious cycle.…”

Can an Integrated Palliative and Oncology Co-rounding Model Reduce Aggressive Care at the End of Life? Secondary Analysis of an Open-label Stepped-wedge Cluster-randomized Trial

“…[35][36][37] Additionally, timing of integration may matter as these outpatient trials integrated palliative care within weeks from metastatic diagnosis, while ours integrated palliative care during hospital admissions, which may occur much later in the disease trajectory and not provide the desired effect on aggressiveness of care. [38][39][40] Because health services are complex interventions with multiple outcomes, intervention design including components, setting selection, and timing needs careful consideration depending on outcomes desired. Second, while previous trials compared palliative care vs no palliative care, our trial compares different ways of palliative care delivery.…”