Journal of Palliative Care

Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting.

A previously published survey to assess barriers to GOC discussions among clinicians on inpatient medical wards was modified for the ambulatory oncology setting and distributed to oncologists from 12 centers in Ontario, Canada. Physicians were asked to rank the importance of various barriers to having GOC discussions (1 = extremely unimportant to 7 = extremely important).

Questionnaires were completed by 30 (24%) of 127 physicians. Respondents perceived patient- and family-related factors as the most important barriers to GOC discussions. Of these, patient difficulty accepting prognosis or desire for aggressive treatment were perceived as most important. Patients’ inflated expectation of treatment benefit was also considered an important barrier to discontinuing active cancer-directed therapy. While physician barriers were ranked lower than patient-related factors, clinicians’ self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Patient’s refusal for referral was the most highly rated barrier to early palliative care referral. Most respondents were nonetheless very or extremely willing to initiate (90%) or lead (87%) GOC discussions.

Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians’ self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.

Goals of care (GoC) conversations optimally begin early in the course of cancer care, yet most happen near the end of life. We sought to describe oncologist-reported facilitators of and barriers to GoC conversations with patients who have advanced cancer.

We conducted individual, semistructured qualitative interviews with oncologists from 4 academic, community, municipal, and rural hospitals in New York and Connecticut. Interview topics included approach to GoC conversations, facilitators, barriers, and organizational influences. We analyzed data using interpretive description. We collected demographic and practice information and surveyed oncologists on their communication skills training. We calculated descriptive statistics for quantitative data.

Oncologists (n = 21) had a mean age of 46 years (range: 34-68), 67% were male, 71% were White, 24% were Asian, 10% were Hispanic, and 5% were Black. They reported an average of 20 years in practice (range: 8-42), and 62% had received training on having GoC conversations. Facilitators included patient’s poor functional status, patient’s high health literacy, family understanding and acceptance, oncologist’s practice experience, and a supportive practice environment. Barriers included certain patient demographic and clinical characteristics, patient religion and culture, patient’s denial, and lack of time.

GoC conversations may be facilitated by enabling oncologists to conduct these conversations despite difficult circumstances and emotional reactions by activating patients and family via increased health literacy and by advancing palliative-informed practice environments.

Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide.

To identify the factors associated with palliative care use among deceased patients with solid cancer tumors.

Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression.

A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds.

Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.

Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population.

A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status.

Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001).

Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.

Patients who are frequently admitted to Medicine inpatient services comprise a distinct subset of readmitted patients about whom not much is known.

We sought to characterize this group including mortality rates, with the goal of better understanding this population.

Observational study of frequently hospitalized patients defined as 4 or more admissions over a 6-month period, with hospitalization defined as nonelective admission to the hospital.

Single large academic medical center.

Adult inpatients on general medicine and medicine subspecialty services.

The number of nonelective medicine hospitalizations, age, clinical conditions and comorbidities, calculation of an age-adjusted Charlson Comorbidity Index (CCI), outpatient and emergency department visits, length of stay, costs of hospitalization, and mortality over a 5-year period. Descriptive statistics were used to characterize variables of interest.

We identified 153 patients with a total of 781 nonelective hospitalizations, totaling greater than 4000 hospital days and with charges of approximately US$9 million during the 6 months. Nearly all had insurance coverage and good outpatient follow-up (median of 7 appointments over the 6-month study period). Only 14% of those admissions qualified for observation status. Over 40% of patients had comorbid mental health disease or chronic narcotic dependence. Twenty-nine percent of patients died within 1 year; 50% were dead within 5 years. Age-adjusted CCI scores ranged annually from 3.00 to 3.58 among surviving patients versus 4.31 to 6.60 among deceased patients.

These findings point to distinct groups of patients who are frequently hospitalized, and therefore would benefit from tailored management strategies: Those with progression of end-stage disease comprised one-third of the group and targeting that subset with palliative care referrals could help decrease readmission rates. Those with recurrent exacerbations of a chronic medical condition could be managed through telemanagement programs. Those with exacerbations of chronic pain could be addressed through collaboration with pain management specialists. Individualized care management plans may be useful for all, especially the latter two groups. Based on differences between survivors and deceased patients, an age-adjusted CCI score of 4 or 5 could be valuable sensitive or specific cutoffs, respectively, for predicting those who would benefit most from palliative care consultation regarding end-of-life goals and management.

The Patient Self-Determination Act (PSDA) requires hospitals, home health agencies, nursing homes, and hospice providers to offer new patients information about advance directives. There is little evidence regarding whether encounters with these health-care providers prompt advance directive completion by patients.

To examine whether encounters with various types of health-care providers were associated with higher odds of completing advance directives by older patients.

Logistic regression using longitudinal data from the 2012 and 2014 waves of the Health and Retirement Study. Participants were 3752 US adults aged 65 and older who reported not possessing advance directives in 2012. Advance directive was defined as a living will and/or durable power of attorney for health care. Four binary variables measured whether participants had spent at least 1 night in a hospital, underwent outpatient surgery, received home health or hospice care, or spent at least one night in a nursing home between 2012 and 2014.

Older adults who received hospital, nursing home, or home health/hospice care were more likely to complete advance directives. Outpatient surgery was not associated with advance directive completion.

Older adults with no advance directive in 2012 who encountered health-care providers covered by the PSDA were more likely to have advance directives by 2014. The exception was outpatient surgery which is frequently provided in freestanding surgery centers not subject to PSDA mandates. It may be time to consider amending the PSDA to cover freestanding surgery centers.

Continuity of care is important for palliative patients in their end of life. In the Netherlands, after-hours primary care for palliative patients is either provided by large-scale general practitioner (GP) cooperatives or GPs choose to give palliative care by themselves while they are not on duty.

To examine the availability of, perceived problems by, and attitude of Dutch GPs regarding providing palliative care for their own patients outside office hours.

Cross-sectional observational study among 1772 GPs from 10 Dutch regions.

Online questionnaire among GPs affiliated with 10 GP cooperatives.

Five hundred twenty-four (29.6%) eligible questionnaires were returned. Of the GPs, 60.8% were personally available outside office hours for their own palliative patients on their own private cell phone and performed home visits if needed. In 33.0%, GPs were willing to make home visits in private time instigated by the GP cooperative and 26.8% were only accessible for telephone consultation by the GP cooperative. In 12.2%, the GP delegated after-hours palliative care completely to the GP cooperative. The GPs predominantly reported “time pressure” problems (17.3%) as a barrier and 61.7% stated that after-hours palliative care is the responsibility of the own GP.

The large majority of Dutch GPs is personally available for telephone consultation and/or willing to provide palliative care for their own patients outside office hours. For the future, it is important to maintain the willingness of GPs to remain personally available for their palliative patients.