The impact of the duration of the palliative care period on cancer patients with regard to the use of hospital services and the place of death: a retrospective cohort study.

BACKGROUND: In order to avoid unnecessary use of hospital services at the end-of-life, palliative care should be initiated early enough in order to have sufficient time to initiate and carry out good quality advance care planning (ACP). This single center study assesses the impact of the PC decision and its timing on the use of hospital services at EOL and the place of death. METHODS: A randomly chosen cohort of 992 cancer patients treated in a tertiary hospital between Jan 2013 -Dec 2014, who were deceased by the end of 2014, were selected from the total number of 2737 identified from the hospital database. The PC decision (the decision to terminate life-prolonging anticancer treatments and focus on symptom centered palliative care) and use of PC unit services were studied in relation to emergency department (ED) visits, hospital inpatient days and place of death. RESULTS: A PC decision was defined for 82% of the patients and 37% visited a PC unit. The earlier the PC decision was made, the more often patients had an appointment at the PC unit (> 180 days prior to death 72% and < 14 days 10%). The number of ED visits and inpatient days were highest for patients with no PC decision and lowest for patients with both a PC decision and an PC unit appointment (60 days before death ED visits 1.3 vs 0.8 and inpatient days 9.9 vs 2.9 respectively, p < 0.01). Patients with no PC decision died more often in secondary/tertiary hospitals (28% vs. 19% with a PC decision, and 6% with a decision and an appointment to a PC unit). CONCLUSIONS: The PC decision to initiate a palliative goal for the treatment had a distinct impact on the use of hospital services at the EOL. Contact with a PC unit further increased the likelihood of EOL care at primary care.

Assessing the utilization of the decision to implement a palliative goal for the treatment of cancer patients during the last year of life at Helsinki University Hospital: a historic cohort study.

Background: To avoid aggressive treatments at the end-of-life and to provide palliative care (PC), physicians need to terminate futile anti-cancer treatments and define the palliative goal of the treatment in time. This single center study assesses the practices used to make the decision that leads to treatment with a palliative goal, i.e., the PC decision and its effect on anti-cancer treatments at the end of life.Material and methods: Patients with a cancer diagnosis treated in tertiary hospital during 1st January 2013 - 31st December 2014 and deceased by the end of 2014 were identified in the hospital database (N = 2737). Of these patients, 992 were randomly selected for this study. The PC decision was screened from patient records, i.e., termination of cancer-specific treatments and a focus on symptom-centered PC.Results: The PC decision was defined in 82% of the patients during the last year of life (49% >30 days and 33% ≤30 days before death, 18% with no decision). The median time from the decision to death was 46 days. Systemic cancer therapy was given during the last month of life in 1%, 36% and 38% (p < .001) and radiotherapy 22%, 40% and 31% (p = .03) cases, respectively; referral to a PC unit was made in 62%, 22% and 11%, respectively (p < .001). In logistic regression analyses younger age, shorter duration of the disease trajectory and type of cancer (e.g., breast cancer) were associated with a lack or late timing of the PC decision.Conclusion: The decision to initiate a palliative goal for the treatment was frequently made for cancer patients but occurred late for every third patient. Younger age and certain cancer types were associated with late PC decisions, thus leading to anti-cancer treatments continuing until close to the death with low access to a PC unit.

End-of-life decisions guiding the palliative care of cancer patients visiting emergency department in South Western Finland: a retrospective cohort study.

BACKGROUND: Until recently, palliative care (PC) resources in Finland have been sparse. To meet the increasing need for PC an end-of-life (EOL) care project has been ongoing in South Western Finland since 2012, and in 2015, a weekday palliative outpatient clinic was established in Turku University Hospital (TUH). The aim of this study was to explore the effect of the project and the PC clinic on the management practices of EOL cancer patients attending the Emergency Department (ED) of TUH from 2013 to 2016. METHODS: The medical records of all cancer patients (ICD-10 codes C00-97) admitted to the ED of TUH between August 1-December 31, in 2013 and 2016, were analyzed: n = 529, n = 432 respectively (2013 and 2016). The analysis focused on those patients in EOL care; n = 77, n = 63, respectively. The late palliative patients were defined by PC decision, thus termination of life-prolonging cancer-specific treatments. The EOL patients were in the imminently dying phase of their illness. The site of referral after an ED visit was also verified together with the documentation on advance care plans (ACP), and the impact of palliative outpatient visits. RESULTS: In 2016, the number of late palliative and EOL patients admitted to the ED has shown a tendency to decrease. The quality of the documentation for treatment goals, do-not-resuscitate (DNR) orders, living wills and connections to primary care providers has improved since 2013. Prior visits to palliative outpatient clinic correlated well with the more comprehensive ACP information: i) DNR order (p = 0.0001); ii) connection to primary care (p = 0.003); iii) documented ICD-10 code Z51.5 (p = 0.0001). CONCLUSIONS: Even modest investments in resources for PC can induce an objective change in the allocation of health care resources, and improve the ACP for the cancer patients at their EOL. A visit to a palliative outpatient clinic may offer one approach for improving the quality and completion of ACP documentation.

End-of-life chemotherapy use at a Finnish university hospital: a retrospective cohort study.

BACKGROUND: Recent trends in the end-of-life (EOL) cancer care have suggested that the levels of treatment are becoming more aggressive. The aim of this single-center study was to evaluate the time from the last intravenous (IV) chemotherapy treatment to death and identify factors correlating with treatment closer to death. MATERIAL AND METHODS: The study included all patients diagnosed with cancer at Turku University Central Hospital between the years 2005 and 2013 (N = 38,982) who received IV chemotherapy during the last year of life (N = 3285). The cohort of patients and their respective clinical information were identified from electronic medical records. Statistical analysis was performed to assess and compare the treatment strategies, taking into account the patient's age, the year they were treated, and the type of cancer they were diagnosed with. RESULTS: A total of 11,250 cancer patients died during the observation time and one-third (N = 3285, 29.2%) of them had received IV chemotherapy during the last year of life. The time from the last IV chemotherapy regimen to death remained consistent across the follow-up time. During the last month of life, every third patient under the age of 50 years and only one-tenth of patients over the age of 80 years received IV chemotherapy. Hematological malignancies and lymphomas were treated closer to death when compared to other diagnostic groups. CONCLUSIONS: During the period of 9 years, the pattern of EOL IV chemotherapy treatment remained stable. Every third patient died at tertiary care. Only 7.2% of patients who received IV chemotherapy during the last year of life were treated 14 days before death, which is in line with international recommendations. However, significant variation in EOL treatment strategies between different diagnosis and age groups were identified.

Assessing the utilization of radiotherapy near end of life at a Finnish University Hospital: a retrospective cohort study.

BACKGROUND: Palliative radiotherapy can improve quality of life for cancer patients during the last months of life. However, very short life expectancy may devastate the benefit of the treatment. This single center study assesses the utilization of radiotherapy during the last weeks of life. MATERIAL AND METHODS: All cancer patients (N = 38,982) treated with radiotherapy (N = 11,395) in Turku University Central Hospital during 2005-2013 were identified in the database consisting of electronic patient records. One fourth (N = 2904, 25.5%) of the radiotherapy treatments were given during the last year of life. The last radiotherapy treatments and the time from the last radiotherapy treatment to death were assessed in regards to patients' age, cancer diagnosis, domicile, place of death and the treatment year. Treatments given during the last two weeks of life were also assessed regarding the goal of treatment and the reason for possible discontinuation. RESULTS: The median time from the last fraction of radiotherapy to death was 84 d. During the last two weeks before death (N = 340), pain (29.4%) was the most common indication for radiotherapy. Treatment was discontinued in 40.6% of the patients during the last two weeks of life, and worsening of general condition was the most common reason for discontinuity (70.3%). The patients receiving radiotherapy during the last weeks of life were more likely to die in tertiary care unit. During the last year of life single-fraction treatment was used only in 7% of all therapy courses. There was a statistically significant (p < .05) decrease in the median number of fractions in the last radiotherapy treatment between 2005-2007 (8 fractions) and 2011-2013 (6 fractions). CONCLUSIONS: Up to 70% of the treatments during the last two weeks of life were not delivered to alleviate pain and utilization of single fraction radiotherapy during the last year of life was infrequent. These observations suggest that practice of radiotherapy during the last weeks of life should be revisited.

Impact of the Regional Palliative Care Pathway on Emergency Room Visits and Hospitalizations.

BACKGROUND/AIM: To explore the effect of palliative care (PC) pathway including home care and end-of-life care beds in the community hospitals supported by a PC unit in the secondary hospital on ER visits and hospitalizations. PATIENTS AND METHODS: Patients with advanced cancer and no further oncologic therapies who visited the ER of the Hyvinkää hospital before (2009) and after (2015) the establishment of the PC pathway were evaluated. RESULTS: A total of 112 patients visited the ER in both years, but revisits decreased from 59% to 38% (p<0.01). The most common symptoms necessitating the visit were pain (20%) and dyspnoea (14%). The proportion of patients admitted to a secondary hospital were 56% and 45% (p=0.016) and to community hospitals 12% and 28% (p<0.001) in 2009 and 2015, respectively. CONCLUSION: Organizing a PC pathway for cancer patients together with primary and secondary care decreases revisits to ER and admissions to secondary hospitals.