Determinants of death in patients with COVID-19 pneumonia treated with venovenous extracorporeal membrane oxygenation support

Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.

Intensive Care Society State of the Art (SOA) 2022 Abstracts

The proceedings contain 117 papers. The topics discussed include: informing local policy through an audit of the assessment, management and outcomes of intermediate and high-risk patients with pulmonary embolism;an initial exploration into the use of a novel virtual reality system to aid rehabilitation in intensive care;surprising chest radiograph- air in mediastinum;exploring tissue donation as part of end-of-life wishes- a duty of care following death on ICU?;the impact of deprivation on respiratory support unit outcomes in COVID-19 patients, and highlights from wave 2 data in Portsmouth;survey of attitudes towards end of life care as a tool in identifying areas for improvement;a quality improvement project regarding family communication within critical care;sleep promotion in a busy inner city high dependency unit;findings from a regional survey of critical care nursing staff focusing on retention and factors that influence wellbeing;and tracking functional recovery post critical illness.

Understanding advance care planning in care homes throughout the COVID-19 pandemic: A critical realist review and synthesis.

BACKGROUND: The COVID-19 pandemic has disrupted advance care planning discussions in care homes, particularly discussions involving relatives and surrogate decision makers. There is a need to collate and examine current evidence to assess the extent of the problem. AIM: To examine the processes and experiences involved in advance care planning in care homes throughout the COVID-19 pandemic. DESIGN: A critical realist review and synthesis. DATA SOURCES: MEDLINE, psycINFO, SCOPUS and CINAHL were searched between December 2019 and May 2022. RESULTS: Eleven studies were included. Communication difficulties associated with remote technologies meant that care home staff's concerns about engaging effectively with relatives further exacerbated the emotional toll of dealing with high death rates in circumstances where staff shortages stretched the capacity of those remaining to provide timely advance care planning discussions. The threat of the pandemic tended to encourage earlier and more frequent advance care planning discussions, though this tendency was partially countervailed by the difficulties that some residents and relatives had in engaging with remote communication modes. There was evidence that education and training in advance care planning increased staff's confidence and readiness to engage in care planning during pandemic conditions. CONCLUSION: Results highlight part of the new context facing staff, relatives and residents in care homes, thus providing valuable insight for future intervention development required to maintain and improve the effectiveness of advance care planning in care homes during and beyond the pandemic.

Anticipatory prescribing in community end-of-life care: systematic review and narrative synthesis of the evidence since 2017.

BACKGROUND: The anticipatory prescribing of injectable medications is recommended practice in controlling distressing symptoms in the last days of life. A 2017 systematic review found practice and guidance was based on inadequate evidence. Since then, there has been considerable additional research, warranting a new review. AIM: To review the evidence published since 2017 concerning anticipatory prescribing of injectable medications for adults at the end-of-life in the community, to inform practice and guidance. DESIGN: Systematic review and narrative synthesis. METHODS: Nine literature databases were searched from May 2017 to March 2022, alongside reference, citation and journal hand-searches. Gough's Weight of Evidence framework was used to appraise included studies. RESULTS: Twenty-eight papers were included in the synthesis. Evidence published since 2017 shows that standardised prescribing of four medications for anticipated symptoms is commonplace in the UK; evidence of practices in other countries is limited. There is limited data on how often medications are administered in the community. Prescriptions are 'accepted' by family caregivers despite inadequate explanations and they generally appreciate having access to medications. Robust evidence of the clinical and cost-effectiveness of anticipatory prescribing remains absent. CONCLUSION: The evidence underpinning anticipatory prescribing practice and policy remains based primarily on healthcare professionals' perceptions that the intervention is reassuring, provides effective, timely symptom relief in the community and prevents crisis hospital admissions. There is still inadequate evidence regarding optimal medications and dose ranges, and the effectiveness of these prescriptions. Patient and family caregiver experiences of anticipatory prescriptions warrant urgent investigation. PROSPERO REGISTRATION: CRD42016052108.

Mortality among people with HIV in the UK in 2021: findings from the National HIV Mortality Review

Background: The National HIV Mortality Review (NHMR) was launched by UK Health Security Agency (UKHSA) and British HIV Association to better recognise causes of death and preventable death, and to describe end-of-life care, among people with HIV. Method(s): UK HIV services submitted data on all known deaths among people with HIV under their care in 2021 through a secure online form. Cause of death was categorised by an epidemiologist and four clinicians using the Coding Causes of Death in HIV protocol. Result(s): In 2021, 101 services reported 606 deaths among people with HIV to NHMR. In 2019, 74 services reported to the NHMR while 121 reported in 2020. Median age at death was 58 [interquartile range (IQR): 56-59] and most (76%) were male. Death cause was ascertainable for 78% (n=475), with the most common being non-AIDS-related cancers (26%), followed by non-AIDS-defining infections (19%), cardiovascular disease (16%), AIDS (9%), substance misuse (8%), respiratory disease (4%), accident/suicide (3%), liver disease (2%) and other causes (11%). COVID- 19 caused or contributed to 11% of all deaths. Thirtythree people (5%) died within a year of HIV diagnosis, 90% of these were diagnosed late (CD4<350 cells/mm3), 80% very late (CD4<200 cells/mm3), 54% diagnosed with AIDS and 33% had documented missed opportunities for earlier diagnosis. Viral suppression (<200 copies/mL) (87%) and treatment coverage (98%) was high with the median time on treatment 13 years [IQR: 8-20]. Common lifestyle risk factors in the preceding year included smoking (33%;n=179), excessive alcohol use (20%;n=103). Other factors included drug use (non-injecting and injecting) and opioid substitution therapy. Death had been expected for 298 (49%) individuals, of whom 230 had discussed end-of-life care and 108 had a documented advanced end-of-life care plan in place. Conclusion(s): Over half of people living with diagnosed HIV are aged over 50. Most deaths were not AIDS related however, one in eleven people with diagnosed HIV in the UK died from AIDS. Of people that died within a year of diagnosis, one in three had documented missed opportunities for earlier HIV diagnosis.

Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey.

BACKGROUND: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care. AIM: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients. DESIGN: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review. SETTING/PARTICIPANTS: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices. RESULTS: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices. CONCLUSION: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life.

End-of-life care in natural disasters including epidemics and pandemics: a systematic review.

BACKGROUND: Natural disasters are becoming more frequent and severe, and place additional strains on end-of-life care services and users. Although end-of-life and palliative care are considered essential components of disaster planning and response, there are gaps in understandings about their real-life application, and how natural disasters impact end-of-life care. OBJECTIVE: To synthesise existing evidence of the impacts of natural disasters (eg, bushfires, communicable pandemics, etc) on end-of-life care. METHODS: A systematic review with a narrative synthesis was undertaken. The review was registered on PROSPERO (registration: CRD42020176319). PubMed, Scopus, PsycINFO, Science Direct and Web of Science were searched for studies published in English between 2003 and 2020, with findings explicitly mentioning end-of-life care impacts in relation to a natural disaster. Articles were appraised for quality using a JBI-QARI tool. RESULTS: Thirty-six empirical studies met the inclusion criteria and quality assessment. Findings were synthesised into three key themes: impacts on service provision, impacts on service providers and impacts on service users. This review demonstrates that natural disasters impact profoundly on end-of-life care, representing a stark departure from a palliative care approach. CONCLUSIONS: Clinical practitioners, policy makers and researchers must continue to collaborate for viable solutions to achieve universal access to compassionate and respectful end-of-life care, during natural disasters. Using models, policies and practices already developed in palliative care, involving those most impacted in disaster planning and anticipating barriers, such as resource shortages, enables development of end-of-life care policies and practices that can be rapidly implemented during natural disasters.

Assessing the Effectiveness of a Standardized and Concise End-of-Life (EOL) Care Toolkit for Medical Residents in a Teaching Hospital: A Mixed Methods Exploratory Study (Sch409)

Outcomes: 1. Assess baseline knowledge, attitudes, and practices on EOL non-pain symptom management among internal medicine residents in a teaching hospital using a cross-sectional survey. 2. Develop a standardized inpatient EOL non-pain symptom management educational toolkit for internal medicine residents. Introduction: With palliative care gaining traction as a vital specialty to help patients living with serious illnesses comes the need for further training of healthcare professionals. Frontline providers such as medical residents can benefit from end-of-life (EOL) care training in symptom management. Method(s): There are three phases (over a period of 4 years) to this study: (1) administration of a needs assessment survey of baseline knowledge, attitudes, and practices on EOL non-pain symptom management;(2) development and implementation of a standardized inpatient EOL symptom management toolkit;and (3) a comparison of pre-and postassessment after the educational intervention. Result(s): The baseline survey had 66 participants. There were six non-pain symptoms that were elicited as important for further education and training. These were anorexia, nausea/vomiting, dyspnea, oral secretions, myoclonus, and delirium. Competency-based comfort and confidence levels were assessed using a Likert scale (1-5), with the highest number as the most comfortable. The residents were noted to be more comfortable with EOL communication compared to symptom management. Furthermore, residents who had had previous EOL care experiences with patients were more comfortable in symptom management. The educational intervention implemented at a later time revealed that there was an improvement in posttest scores for EOL symptom management. Discussion(s): This study highlights the needs and gaps in EOL symptom management training for medical residents. The implementation of a standardized inpatient EOL symptom management toolkit might serve as a potential intervention to address the needs and narrow gaps in medical training. This can serve as a possible template for other institutions to integrate an EOL care curriculum in medical residency. Limitations of the study include a small sample size, implementation during the COVID-19 pandemic, variable participant response rate, and interrupted timelines. The next steps include ongoing training for all residents, long-term follow-up postintervention, and institutional buy-in.Copyright © 2023

The Digital Divide in End-of-Life Care: Evaluating Health Policies to Bridge the Gap in Virtual Care (FR206B)

1. Identify clinical and sociodemographic disparities associated with virtual end-of-life care and understand the role of physician practice behaviors in such disparities. 2. Recognize potential clinical and health policy initiatives that may help to alleviate disparities in virtual end-of-life care. Virtual care was rapidly expanded in Ontario, Canada, during the COVID-19 pandemic following the introduction of new fee codes on March 14, 2020, that incentivized physician delivery of virtual care, including end-of-life care (EOLC). The objective of this study was to measure the associated impact of these fee incentives on disparities in access to virtual EOLC and the variation in use according to a physician's annual practice volume. This population-based cohort study used linked health administrative data of adults in the last three months of life between January 25, 2018, and December 31, 2022, in Ontario, Canada, with practice data for the 38,282 physicians most responsible for their EOLC. Modified Poisson regression was used to measure the association between the intervention and use of virtual EOLC. Multilevel hierarchical logistic regression was used to measure the association between tertiles of annual physician practice volume (Low-bottom, 25%;Average, 25%-75%;High-top, 25%). There were 14,189 people (12%) who received virtual EOLC before March 14, 2020, and 100,934 people (88%) after that date, representing a 9-fold increase (RR, 9.22;95% CI, 8.92-9.52;p<0.0001). Of the measured sociodemographic variables, 10/51 (19.6%) were associated with a lower probability of receiving virtual EOLC before the policy intervention;7 of these 10 had a RR of ≥1 after the intervention (p<0.05). High annual physician volume accounted for 28%-36% of the variation in receipt of virtual EOLC before March 14, 2020, and 10%-12% after March 14, 2020. The introduction of new physician fee codes to broaden the delivery of virtual EOLC was associated with a substantial increase in virtual EOLC utilization and a leveling of preexisting disparities in use among different demographic groups. Physician-level factors accounted for substantial variation in receipt of virtual care, though these effects were attenuated over time as virtual care was more broadly utilized. [ FROM AUTHOR] Copyright of Journal of Pain & Symptom Management is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Using a Palliative Extubation Simulation-Based Learning Model to Teach Key Palliative Medicine Topics and Skills Across Graduate and Undergraduate Medical Education (Sch472)

Outcomes: 1. Self-report the ability to use a palliative extubation simulation curriculum to teach key palliative care topics to learners across various levels. 2. Self-report the ability to mitigate communication and procedural errors associated with suboptimal palliative extubations to provide maximum comfort for patients and families at end of life. Background(s): The COVID-19 pandemic revealed gaps in the provision of end-of-life (EOL) care. In particular, the high number of mechanically ventilated patients at the EOL highlighted the need to standardize evidence-based palliative extubation (PE) amidst significant practice variation. Suboptimal PE practices can worsen symptoms, inappropriately hasten death, and add undue stress on patients, families, and healthcare staff. Effective training models are needed to standardize evidence-based PE. Simulation-based learning (SBL) has been shown to effectively improve medical knowledge, procedural proficiency, and interprofessional communication, all of which are necessary to successfully perform a PE. Unfortunately, the use of SBL in palliative care (PC) education is sparse. Method(s): An innovative educational activity using high-fidelity simulation and SBL models was created to teach key PC topics and skills within the context of a simulated PE procedure. The curriculum consists of a 1-hour didactic followed by 2 hours of simulation, divided into 4 sections. The simulation is designed to teach complex symptom management, communication strategies, and leadership skills. Each section concludes with a debrief to provide feedback and teaching points. This curriculum was piloted over multiple years among palliative medicine fellows. It will expand to include medical students this academic year with the plan to be further incorporated into medical resident education in the future. The following validated questionnaires will be used to study the efficacy of this SBL model: Student Satisfaction and Self-Confidence in Learning Scale, Simulation Design Scale, and Educational Practices Questionnaire. Participants will complete the questionnaires following the simulation. Conclusion(s): Multiple specialties have adopted SBL as an effective modality to enhance training. The use of SBL in palliative medicine education is relatively sparse. An innovative PE-simulation educational activity may provide an optimal way to teach key PC concepts across graduate and undergraduate medical education.Copyright © 2023

Navigating the Storm: Palliative Care Team Supportive Insights During the COVID-19 Pandemic (Sci242)

Outcomes: 1. Analyze protective and risk factors affecting registered nurses who provided end-of-life care to critically ill patients during the COVID pandemic. 2. Evaluate ways involvement of palliative care teams can improve the experience of registered nurses who provided care to critically ill patients during the COVID pandemic. Introduction: Minimal research documents the lived experience of intensive care unit (ICU) registered nurses (RNs) providing end-of-life care during the COVID-19 pandemic. The mixed-methods study aimed to understand the impact of end-of-life care and communication during the COVID-19 pandemic to identify protective and risk factors influencing the sample population. Method(s): Surveys were distributed in early summer 2021 following the initial wave of COVID patient influx. Responses for nurses in COVID-designated units were compared to non-COVID units. The survey included demographic questions, the ProQOL survey instrument (measuring burnout, compassion fatigue, and secondary traumatic stress), and open-ended questions to identify protective factors and unique challenges. Both quantitative and qualitative analyses were conducted. Result(s): A total of 311 registered nurses were eligible to complete the survey across five critical care settings between May 3, 2021, and June 15, 2021. A total of 107 participants responded to the survey;however, 17 were incomplete. 90 allowed for comparative analysis. The vast majority (n= 71;78.89%) had experience caring for COVID patients. The study population consisted of COVID-designated unit RNs (n=48;53.33%) and non-COVID designated units (n=42;46.67%). Two-group comparison indicated significant differences for compassion (p=0.041), burnout (p=0.014), and stress subscales (p=0.002). Analysis between both groups revealed significantly lower mean compassion scores and significantly higher burnout and stress scores among those working in the COVID-designated units. Nurses in both groups were able to identify protective factors and challenges. Conclusion(s): Despite higher levels of burnout and stress and lower levels of compassion, nurses readily identified various protective factors that helped them cope with challenges. Involvement of palliative care teams, who are uniquely equipped to deal with complicated symptom management needs, communication challenges, and difficult emotions, can further improve the experience of bedside nurses providing care to patients by helping navigate the challenges posed by the COVID-19 pandemic.Copyright © 2023

Why Does It Feel Different? Provider Moral Distress in Removing Unwanted Aggressive Intervention for Conscious Patients (TH123B)

Outcomes: 1. Illustrate increased moral distress associated with removing unwanted aggressive interventions for conscious patients compared to unconscious patients. 2. Demonstrate the importance of the interdisciplinary team in supporting providers experiencing moral distress. When providing end-of-life care, removing unwanted aggressive intervention is more challenging in a conscious patient. If the intent to provide comfort and reduce suffering is the same, why does it feel different when the patient is conscious? This case examines the moral distress experienced by the palliative care team who assisted a conscious patient with Duchenne muscular dystrophy achieve his goal of liberation from the ventilator. A 41-year-old male with Duchenne muscular dystrophy and prior COVID-19 infection presented with respiratory failure. The patient had COVID-19 infection in April 2022 and was ventilator dependent since then. The palliative care team was consulted for goals of care discussion. After extensive discussion with the patient and his family, the patient decided to be disconnected from the ventilator and wanted a peaceful passing because long-term ventilatory support was no longer acceptable to him. He was afraid of being aware of struggling to breathe and requested to be asleep throughout this process. Specifically, he said he wanted "to close my eyes and see [my family] on the other side." When the patient was comfortable and asleep as he and his family desired, he was disconnected from the ventilator and died peacefully with his family around him. During this process, the palliative care team's intent was clear: follow the patient's wishes and provide comfort. Ethically, there is no difference in removing unwanted aggressive interventions between conscious and unconscious patients, but the team experienced significantly more distress in this case. After the patient's death, the interdisciplinary team provided support to help the palliative care team work through the distress experienced.Copyright © 2023

Home or hospital? An observational study of what affects the place of death of people with COVID-19 in Mexico.

BACKGROUND: Out-of-hospital deaths increased during peak coronavirus disease 2019 (COVID-19) pandemic periods. However, aside from COVID-19 severity, which variables are related to being hospitalized have not been properly studied. We examine the association of several variables with dying at home from COVID-19 as opposed to in a hospital. METHODS: We used COVID-19 open data from Mexico City from March 2020 until February 2021. A causal model was prespecified to identify variables of interest. Adjusted logistic regressions were performed to calculate ORs for associations between variables of interest and dying out of hospital due to COVID-19. RESULTS: Among 61 112 people who died due to COVID-19, 8080 died out of hospital. Older age (OR 3.49, age 90 vs 60 y), male sex (OR 1.18) and higher bed occupancy (OR 2.68, 90% vs 50% occupancy) were positively associated with dying outside of hospital. CONCLUSION: Older age could confer different patient wishes or less ability to look for healthcare. Higher bed occupancy may have prevented hospital admission from people who required in-hospital care.

Free-text analysis of general practice out-of-hours (GPOOH) use by people with advanced cancer: an analysis of coded and uncoded free-text data.

BACKGROUND: People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets. AIM: To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. DESIGN AND SETTING: An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013-2015. METHOD: Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing. RESULTS: More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations. CONCLUSION: GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses.

Deaths at home, area-based deprivation and the effect of the Covid-19 pandemic: An analysis of mortality data across four nations.

BACKGROUND: The number and proportion of home deaths in the UK increased during the Covid-19 pandemic. It is not known whether these changes were experienced disproportionately by people from different socioeconomic groups. AIM: To examine the association between home death and socioeconomic position during the Covid-19 pandemic, and how this changed between 2019 and 2020. DESIGN: Retrospective cohort study using population-based individual-level mortality data. SETTING/PARTICIPANTS: All registered deaths in England, Wales, Scotland and Northern Ireland. The proportion of home deaths between 28th March and 31st December 2020 was compared with the same period in 2019. We used Poisson regression models to evaluate the association between decedent's area-based level of deprivation and risk of home death, as well as the interaction between deprivation and year of death, for each nation separately. RESULTS: Between the 28th March and 31st December 2020, 409,718 deaths were recorded in England, 46,372 in Scotland, 26,410 in Wales and 13,404 in Northern Ireland. All four nations showed an increase in the adjusted proportion of home deaths between 2019 and 2020, ranging from 21 to 28%. This increase was lowest for people living in the most deprived areas in all nations, with evidence of a deprivation gradient in England. CONCLUSIONS: The Covid-19 pandemic exacerbated a previously described socioeconomic inequality in place of death in the UK. Further research to understand the reasons for this change and if this inequality has been sustained is needed.

Providing Educational Resources during the Pandemic for Advanced Breast Cancer Patients

Significance and Background: Metastatic Breast Cancer (MBC) or Advanced Breast Cancer (ABC) is multifaceted and requires high levels of support and resource utilization. The ABC Program at MD Anderson Cancer Center began in 2014 with a goal to increase the quantity and quality of life for patients living with MBC. It offers emotional support, personalized visits with a nurse practitioner navigator, access to clinical trials, specialty clinics, tailored patient education and innovative care projects. Prior to COVID-19, the ABC Program held a 90-minute quarterly town hall series featuring 2-3 presenters and topics of patient interest. In response to COVID-19, it pivoted to a weekly virtual 60-minute educational series called "ABCs of Healthy Living in Challenging Times" that is for patients with breast cancer, caregivers, faculty, staff, community members and advocates. Purpose(s): To address COVID-19 social-distancing related isolation and changes to healthcare, build community, empower patients, and educate on diverse topics including patient services, treatment, symptom management and quality of life. Interventions and Evaluation: The series was facilitated by a nurse practitioner navigator via Zoom. A distribution list created from town hall meetings was the basis for the series' notices and has grown by referrals, word of mouth and marketing opportunities;it began with less than 150 people and has grown to more than 550 people. The facilitator offered a format where the attendees and speakers could interact visually and verbally with each other. From 4/2020 to 6/2022, 104 webinars were held for 2,546 attendees for an average of 24 attendees each week. Topics covered were side effect management/quality of life/healthy lifestyle (26%), patient education/empowerment (18%), treatment (19%), clinical trials/research (11%), quality of life related to COVID-19 (8%), COVID-19 (7%), innovation projects (4%), palliative/end of life care (7%), and financial/disability concerns (3%). The series was evaluated using the Qualtrics survey software (n=53). Respondents said that the series has positively influenced their interactions with healthcare providers (65%), how patients with MBC think about their cancer experiences (65%) and provided an opportunity to connect with others like themselves (65%). Respondents stated actions taken based on the series: shared the information with family/friends (77%), joined or remained in a support group (34%), spoke with a provider for information and services (32%), requested an appointment with the ABC Program or other specialty clinics (26%), started a new healthy behavior (21%), joined a clinical trial (11%), or started using a patient reported outcome tool (9%). The series served mostly patients living with MBC (70%), established patients at MD Anderson (38%) or patients at MD Anderson as well as a community cancer center (17%). Most respondents indicated that they attended about half of the time, usually or always (60%) and are very or completely satisfied with the series (92%). Demographics of the respondents were White (77%), Black (13%), Asian (4%) and Hispanic (16%). Discussion(s): The ABC Program pivoted to COVID-19 by offering services virtually. The virtual series has allowed for more digestible patient education, varied presentations, and participation for those living outside of Houston, TX. Peer support and continuing education are imperative dynamics for patients to use their voice to impact their overall quality of life. The series has impacted attendees with a change in behavior when speaking with their clinical team, awareness and utilization of support resources, and starting healthy behaviors. While the series was created in response to demands of COVID-19, it effectively addressed psychosocial and educational needs and overall quality of life of MBC patients. The series was an easy intervention to initiate with lasting changes relative to the effort and resources required.

Referral patterns of metastatic breast cancer patients to Palliative Care team at a Cancer Center in Brazil

Introduction: Breast cancer is the most common cancer in women and the leading cause of cancerrelated death in women worldwide. The high prevalence of physical and psychosocial suffering among breast cancer patients and their families justifies the need for an early interdisciplinary approach by a palliative care team. The effectiveness of early palliative care for patients with advanced cancer has been demonstrated in many studies. Early referral to outpatient palliative care services improves symptom control, reduces suffering and improves quality of end-of-life care. Aim(s): Evaluation of referral patterns of metastatic breast cancer patients to the outpatient embedded palliative care team. Method(s): We retrospectively retrieved data from electronic medical records of patients who were treated at a private community oncology practice in Brazil who died from metastatic breast cancer during the years of 2018 until 2021.We evaluated the patient's follow-up time by the palliative care team (follow-up > 12 weeks or not) and the year of referral to the service (pre-2020 vs 2020 and later) associated to the service referral type: Late referral (more than 8 weeks of metastatic diagnosis) or early referral. Each group was followed-up by cancer physicians and after referral was also followed-up by a palliative care multidisciplinary team who regularly evaluated cancer patients during their treatments at outpatient setting. During COVID-19 pandemic, some patients were evaluated by telemedicine appointments. We performed univariate comparisons analysis by Fisher's Exact Test. p < 0.1 was deemed as statistically significant. Result(s): Of the 211 patients whose data were assessed, 99 patients were referred to Palliative Care team before 2020 and 112 patients after 2020. 13.1% of patients pre-2020 received early palliative care versus 33.9% of patients in the post-2020 referral group, resulting in a 3.37-fold odds of an early palliative care integration after 2020 (OR 3.37, CI95: 1.61 - 7.45;p< 0.001). Overall, 30.4% of longer follow-up patients were an early referral versus 19.3% of the shorter follow-up, resulting in an 82% greater chance (OR 1.82, CI: 0.92-3.63;p< 0.1) of prolonged assistance with early referral. Conclusion(s): In this analysis, early palliative care integration for patients with metastatic breast cancer has increased after 2019 despite the COVID-19 pandemic, leading to prolonged time of accompaniment by the multidisciplinary palliative care team. This suggests that even in the face of this challenging moment, a mature and consolidated service is offered by the palliative care team. Also, according to previous data in literature, prematurely integration show signs of correlation with better quality of life and death, supporting early palliative care for this group of patients. However, further work is needed to examine the effect of this care model in our cohort.

National and international non-therapeutic recommendations for adult palliative and end-of-life care in times of pandemics: A scoping review.

OBJECTIVE: The care of seriously ill and dying people is an important task, especially in times of pandemics and regardless of the patients' infection status. Before the SARS-CoV-2 pandemic, healthcare systems were not sufficiently prepared for the challenges of palliative and end-of-life care during a pandemic. The aim was to identify and synthesize relevant aspects and non-therapeutic recommendations of palliative and end-of-life care of seriously ill and dying people, infected and uninfected, and their relatives after one year into the pandemic to outline what actions, practices, and procedures were taken to deal with the pandemic and its consequences. METHOD: A scoping literature review following the methods of the PRISMA-ScR. The electronic literature search was conducted in 09/2020 and updated in 02/2021 using MEDLINE (Pubmed), with no restriction of publication date and eligibility criteria. In addition, a manual search was carried out. RESULTS: A total of 280 studies met the inclusion criteria and three main aspects have emerged. The reduction of physical contact due to the risk of infection severely limited the work of palliative care professionals and solutions had to be found to maintain palliative and end-of-life care structures. This has been accompanied by strict visitor restrictions and the need to support patients, relatives, and enable contact. The third relevant aspect is the integration of specialist palliative care expertise into other clinical settings. SIGNIFICANCE OF RESULTS: This scoping review demonstrates the need for basic palliative care training for every healthcare professional. It supports the importance of developing a national strategy for palliative care in pandemic times in every country, including the digitalization of the healthcare sector to offer telecommunication/telemedicine.

Global Research Trend and Bibliometric Analysis of Current Studies on End-of-Life Care.

The growing emphasis on evidence-based practice has led to a need for more research on healthcare disciplines, and for the synthesis and translation of that research into practice. This study explored the global research trend in regard to End-of-Life Care (EoLC), and assessed the impact and influence, on the scientific community, of relevant EoLC publications EoLC. Over 350,000 related publications on EoLC were retrieved from three databases (PubMed, Scopus, and Web of Science). Our analysis of the global research trend revealed an exponential rise in the number of related publications on EoLC since the year 1837. This study assessed the bibliometric information of 547 current journal publications on EoLC, sorted by relevance, from the three databases. The USA (47.3%) and the UK (16.1%) were the most productive countries, in terms of the number of relevant publications. The bibliometric analysis also revealed which EoLC research was most impactful and influential, from different parameters including documents, authors, sources, and organisations. The keyword analysis further suggested the growing importance of advance care planning and decision-making in regard to EoLC, as well as an episodic upsurge of EoLC publications related to the COVID-19 pandemic. There were few collaborations among the prolific research on EoLC. This study recommends increased research collaboration across the globe, for wider wisdom-sharing on EoLC issues.