Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed.
Objective:
To identify risk factor patient profiles associated with PCC timing before death.
Methods:
Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables.
Results:
Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity.
Conclusions:
A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
GieniuszMNunesRSahaVRensonASchubertFDCareyJ. Earlier goals of care discussions in hospitalized terminally Ill patients and the quality of end-of-life care: a retrospective study. Am J Hosp Palliat Care. 2018;35(1):21–27.
2.
HigginsonIJDavesonBAMorrisonRS, et al.Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries. BMC Geriatr. 2017;17(1):271.
3.
YunYHYouCHLeeJS, et al.Understanding disparities in aggressive care preferences between patients with terminal illness and their family members. J Pain Symptom Manage. 2006;31(6):513–521.
4.
HeylandDKHeylandRDodekP, et al.Discordance between patients’ stated values and treatment preferences for end-of-life care: results of a multicentre survey. BMJ Support Palliat Care. 2017;7(1):292–299.
5.
BischoffKESudoreRMiaoYBoscardinWJSmithAK. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc. 2013;61(2):209–214.
6.
MackJWWeeksJCWrightAABlockSDPrigersonHG. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol. 2010;28(7):1203–1208.
7.
Smith-HowellERHickmanSEMeghaniSHPerkinsSMRawlSM. End-of-life decision making and communication of bereaved family members of African Americans with serious illness. J Palliat Med. 2016;19(2):174–182.
8.
WrightAAKeatingNLAyanianJZ, et al.Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284–292.
9.
ZhangBNilssonMEPrigersonHG. Factors important to patients’ quality of life at the end of life. Arch Intern Med. 2012;172(15):1133–1142.
10.
HuynhTNKleerupECWileyJF, et al.The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173(20):1887–1894.
11.
Cardona-MorrellMKimJTurnerRMAnsteyMMitchellIAHillmanK. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care. 2016;28(4):456–469.
12.
Institute of Medicine (IOM). Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. IOM; 2015.
13.
MackJWCroninAKeatingNL, et al.Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol. 2012;30(35):4387–4395.
14.
O’ConnorNRJunkerPAppelSMStetsonRLRohrbachJMeghaniSH. Palliative care consultation for goals of care and future acute care costs: a propensity-matched study [published online 2017]. Am J Hosp Palliat Care. 2018;35(7):966–971
15.
ZhangBWrightAAHuskampHA, et al.Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med. 2009;169(5):480–488.
16.
DeteringKMHancockADReadeMCSilvesterW. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
17.
O’ConnorNRMoyerMEBehtaMCasarettDJ. The impact of inpatient palliative care consultations on 30-day hospital readmissions. J Palliat Med. 2015;18(11):956–961.
18.
BernackiRBlockS. American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.
19.
PatelMISundaramVDesaiM, et al.Effect of a lay health worker intervention on goals-of-care documentation and on health care use, costs, and satisfaction among patients with cancer: a randomized clinical trial. JAMA Oncol. 2018;4(10):1359–1366.
20.
MackJWCroninATabackN, et al.End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med. 2012;156(3):204–210.
21.
EmilojuOEDjiboDAMFordJG. Association between the timing of goals-of-care discussion and hospitalization outcomes in patients with metastatic cancer [published online 2019]. Am J Hosp Palliat Care. 2020;37(6):433–438.
22.
LeungJMUdrisEMUmanJAuDH. The effect of end-of-life discussions on perceived quality of care and health status among patients with COPD. Chest. 2012;142(1):128–133.
23.
HansonLCUsherBSpragensLBernardS. Clinical and economic impact of palliative care consultation. J Pain Symptom Manage. 2008;35(4):340–346.
24.
KhandelwalNBenkeserDCCoeNBCurtisJR. Potential influence of advance care planning and palliative care consultation on ICU costs for patients with chronic and serious illness. Crit Care Med. 2016;44(8):1474–1481.
25.
MayPNormandCMorrisonRS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17(9):1054–1063.
26.
MorrisonRSPenrodJDCasselJB, et al.Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783–1790.
27.
PenrodJDDebPDellenbaughC, et al.Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973–979.
28.
WhitfordKShahNDMoriartyJBrandaMThorsteinsdottirB. Impact of a palliative care consult service. Am J Hosp Palliat Care. 2014;31(2):175–182.
29.
GaertnerJSiemensWMeerpohlJJ, et al.Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ. 2017;357:j2925.
30.
GreerJAPirlWFJacksonVA, et al.Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol. 2012;30(4):394–400.
31.
KozlovECarpenterBDThorstenMHeilandMAgarwalA. Timing of palliative care consultations and recommendations: understanding the variability. Am J Hosp Palliat Care. 2015;32(7):772–775.
32.
ScibettaCKerrKMcGuireJRabowMW. The costs of waiting: implications of the timing of palliative care consultation among a cohort of decedents at a comprehensive cancer center. J Palliat Med. 2016;19(1):69–75.
33.
RobbinsSGHackstadtAJMartinSShinallMCJr. Implications of palliative care consultation timing among a cohort of hospice decedents. J Palliat Med. 2019;22(9):1129–1132.
34.
SteinhauserKEChristakisNAClippECMcNeillyMMcIntyreLTulskyJA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476–2482.
35.
HjorthNEHaugenDFSchaufelMA. Advance care planning in life-threatening pulmonary disease: a focus group study. ERJ Open Res. 2018;4(2):9.
36.
EuesSK. End-of-life care: improving quality of life at the end of life. Prof Case Manag. 2007;12(6):339–344.
KelleyASCovinskyKEGorgesRJ, et al.Identifying older adults with serious illness: a critical step toward improving the value of health care. Health Serv Res. 2017;52(1):113–131.
40.
AndriyashinATimofeevR. Classification and Regression Tree Analysis (CART). Center for Applied Statistics and Economics, Humboldt Universitat Zuberlin; 2005.
41.
SteinbergD.Rules of thumb when working with small data samples: CART. Dan Steinberg’s Blog. Salford Systems; 2018.
42.
StarrLUlrichCMMeghaniSH. Associations Between End-of-Life Care Planning Communications, Treatments, and Costs at the End-of-Life in Persons with Cancer: An Integrative Review with Ethical Considerations. University of Pennsylvania, NewCourtland Center for Transitions and Health; 2018.
43.
BaramDDaroowallaFGarciaR, et al.Use of the all patient refined-diagnosis related group (APR-DRG) risk of mortality score as a severity adjustor in the medical ICU. Clin Med Circ Respirat Pulm Med. 2008;2:19–25.
44.
MerlinoJIKestranekCBokarDSunZNissenSELongworthDL. HCAHPS survey results: impact of severity of illness on hospitals’ performance on HCAHPS survey results. J Patient Exp. 2014;1(2):16–21.
45.
NevillePG. Decision Trees for Predictive Modeling. SAS Institute Inc; 1999:1999.
46.
ChengZNakatsugawaMHuC, et al.Evaluation of classification and regression tree (CART) model in weight loss prediction following head and neck cancer radiation therapy. Adv Radiat Oncol. 2018;3(3):346–355.
47.
KuhnLPageKWardJWorrall-CarterL. The process and utility of classification and regression tree methodology in nursing research. J Adv Nurs. 2014;70(6):1276–1286.
48.
ZimmermanRKBalasubramaniGKNowalkMP, et al.Classification and regression tree (CART) analysis to predict influenza in primary care patients. BMC Infect Dis. 2016;16(1):503.
49.
GreeneMZHughesTLHanlonAHuangLSommersMSMeghaniSH. Predicting cervical cancer screening among sexual minority women using classification and regression tree analysis. Prev Med Rep. 2019;13:153–159.
50.
LewisR. An Introduction to Classification and Regression Tree (CART) Analysis. Annual Meeting of the Society for Academic Emergency Medicine; 2000.
51.
RomanoPSChanBK. Risk-adjusting acute myocardial infarction mortality: are APR-DRGs the right tool?Health Serv Res. 2000;34(7):1469–1489.
52.
SmithAKSudoreRPerez-StableE. Palliative care for Latino patients and their families: “whenever we prayed, she wep. JAMA. 2009;301(10):1047–E1041.
53.
VegaWARodriguezMAGruskinE. Health disparities in the Latino population. Epidemiol Rev. 2009;31:99–112.
54.
VolandesAEPaasche-OrlowMGillickMR, et al.Health literacy not race predicts end-of-life care preferences. J Palliat Med. 2008;11(5):754–762.
55.
National Hospice and Palliative Care Organization (NHPCO). Facts and Figures: Hospice Care in America. NHPCO; 2017;2019.
56.
RickersonEHarroldJKapoJCarrollJTCasarettD. Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better?J Am Geriatr Soc. 2005;53(5):819–823.
57.
SchockettERTenoJMMillerSCStuartB. Late referral to hospice and bereaved family member perception of quality of end-of-life care. J Pain Symptom Manage. 2005;30(5):400–407.
58.
WachtermanMWHailpernSMKeatingNLKurella TamuraMO’HareAM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Intern Med. 2018;178(6):792–799.
59.
MathewsKSNelsonJE. Palliative care in the ICU of 2050: past is prologue. Intensive Care Med. 2017;43(12):1850–1852.
60.
TurnbullAEBossletGTKrossEK. Aligning use of intensive care with patient values in the USA: past, present, and future. Lancet Respir Med. 2019;7(7):626–638.
61.
TabibianBESalehaniAAKuhnENDavisMCShankCDFisher IiiWS. Transitioning the treatment paradigm: how early palliative care service involvement affects the end-of-life course for critically ill patients in the neuro-intensive care unit. J Palliat Med. 2018;22(5):489–492.
62.
O’MahonySMcHenryJBlankA, et al.Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010;24(2):154–165.
63.
JonesBWBernsteinC. Palliative care triggers in the intensive care unit: a pilot success story. Dimens Crit Care Nurs. 2017;36(2):106–109.
64.
McCarrollCM. Increasing access to palliative care services in the intensive care unit. Dimens Crit Care Nurs. 2018;37(3):180–192.
65.
LoPrestiMADementFGoldHT. End-of-life care for people with cancer from ethnic minority groups: a systematic review. Am J Hosp Palliat Care. 2016;33(3):291–305.
66.
LorenzKA. Quality of end-of-life care: how far have we come in addressing the needs of multicultural patients?Ann Palliat Med. 2017;6(1):3–5.
67.
PeriyakoilVSNeriEKraemerH. Patient-reported barriers to high-quality, end-of-life care: a multiethnic, multilingual, mixed-methods study. J Palliat Med. 2016;19(4):373–379.
68.
BarnatoAEAnthonyDLSkinnerJGallagherPMFisherES. Racial and ethnic differences in preferences for end-of-life treatment. J Gen Intern Med. 2009;24(6):695–701.
69.
LoggersETMaciejewskiPKPaulkE, et al.Racial differences in predictors of intensive end-of-life care in patients with advanced cancer. J Clin Oncol. 2009;27(33):5559–5564.
70.
IngersollLTAlexanderSCPriestJ, et al.Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. Patient Educ Couns. 2019;102(6):1098–1103.
71.
HanchateAKronmanACYoung-XuYAshASEmanuelE. Racial and ethnic differences in end-of-life costs: why do minorities cost more than whites?Arch Intern Med. 2009;169(5):493–501.
72.
MantwillSMonestel-UmanaSSchulzPJ. The relationship between health literacy and health disparities: a systematic review. PLoS One. 2015;10(12):e0145455.
73.
HyattRDeanJO’NeillMPatelNAbu-RabiaMTaylorJ. The frailest of the frail? addressing the palliative care needs of frail older patients. Future Healthc J. 2018;5(1):10–14.
74.
LeeYJYooJWHuaLKimPCKimSJShenJJ. Ten-year trends of palliative care utilization associated with multiple sclerosis patients in the United States from 2005 to 2014. J Clin Neurosci. 2018;58:13–19.
75.
KirkpatrickJNHauptmanPJSwetzKM, et al.Palliative care for patients with end-stage cardiovascular disease and devices: a report from the palliative care working group of the geriatrics section of the American College of Cardiology. JAMA Intern Med. 2016;176(7):1017–1019.
76.
JohnstonGMLethbridgeLTalbotP, et al.Identifying persons with diabetes who could benefit from a palliative approach to care. Can J Diabetes. 2015;39(1):29–35.
77.
HwangFPentakotaSRGlassNEBerlinALivingstonDHMosenthalAC. Older patients with severe traumatic brain injury: national variability in palliative care. J Surg Res. 2020;246:224–230.
78.
PollackLRGoldsteinNEGonzalezWC, et al.The frailty phenotype and palliative care needs of older survivors of critical illness. J Am Geriatr Soc. 2017;65(6):1168–1175.
79.
ChangRSPoonWS. “Triggers” for referral to neurology palliative care service. Ann Palliat Med. 2018;7(3):289–295.
80.
HussainJAllgarVOliverD. Palliative care triggers in progressive neurodegenerative conditions: an evaluation using a multi-centre retrospective case record review and principal component analysis. Palliat Med. 2018;32(4):716–725.
81.
PsotkaMAMcKeeKYLiuAYEliaGDe MarcoT. Palliative care in heart failure: what triggers specialist consultation?Prog Cardiovasc Dis. 2017;60(2):215–225.
82.
BlockSDBernierGMCrawleyLM, et al.Incorporating palliative care into primary care education. National consensus conference on medical education for care near the end of life. J Gen Intern Med. 1998;13(11):768–773.
83.
RamanayakeRPDilankaGVPremasiriLW. Palliative care; role of family physicians. J Family Med Prim Care. 2016;5(2):234–237.
