Winning Abstracts from the 2011 Medical Student Abstract Competition: Effect of Palliative Care Services on End of Life Care in Cancer Patients
Author: Tracy Davies, Creighton University School of Medicine, Class of 2012
Introduction: End-of-life (EOL) cancer care affects a large number of Americans each year. Terminal cancer patients have been experiencing increasing use of overly aggressive anticancer treatments and disparities in access to hospice services. Hence, EOL care has become increasingly aggressive but is not associated with higher quality care or lower mortality rate. This raises concerns about the appropriateness of aggressive EOL care and the possibility of dedicated palliative care teams to help attenuate this phenomenon. Previously identified indicators of aggressive EOL care are: use of chemotherapy in last 30 days, low rates of hospice use and interventions resulting in ER visits, hospitalizations or ICU admissions. We compared the trends of aggressiveness of care amongst the Veteran's Affairs cancer population in our hospital and assessed the effects of palliative care (PC) services on EOL care.
Methods: We identified the last 100 cancer patients at our university's Veteran's Hospital who died in 2008 and the last 100 cancer patients who died in 2002. Age, date of diagnosis, survival, date of palliative consult, hospice initiation, hospice duration, treatments received and location of patient in the last 30 days of life were recorded.
Results: Mean age was 72 years (range: 45-90). 170 (85%) patients had metastatic disease. In the last 30 days of life, cancer patients had more aggressive care in 2008 than 2002 in terms of 1) incidences of chemotherapy administered (18% vs. 10%, p = 0.04), 2) ICU admissions (33% vs. 6%, p < 0.001) 3) >14 days of hospital stay (38% vs. 6%, p < 0.001) and 4) hospital deaths (38% vs. 18%, p < 0.01). The palliative care (PC) service program was initiated in 2003. In 2008, in the last 30 days of life, patients with PC consults = 2 weeks before death had fewer ICU admissions (24% vs. 73%), ER visits (0% vs. 25%), and hospitalizations (8% vs. 40%) when compared to patients without or with late PC consults. Patients with timely PC consults also had more hospice consults (76% vs. 38%, p < 0.001), were less likely to die in the hospital (26% vs. 43%, p = 0.04) and less likely to spend = 3 days in hospice before death (29% vs. 55%, p = 0.004).
Conclusion: Over the last decade, EOL care has gotten more aggressive in the VA healthcare system. Nevertheless, timely PC services improve the quality of EOL care and should be considered in every patient with metastatic cancer regardless of treatment goals.