Palliative Care Reduces Aggressive End-of-Life Interventions

Pam Harrison

August 24, 2017

Consultation with a palliative care provider substantially reduces aggressive end-of-life care compared with end-of-life care with no palliative component. Also, the earlier the consultation, the greater the reduction in healthcare use, a retrospective observational study indicates.

The study was published online August 22 in the Journal of Oncology Practice.

"We have multiple clinical trials that provide strong evidence that palliative care in oncology improves patient quality of life, decreases patient symptoms, improves caregiver well-being and may improve patient survival," senior author, James Murphy, MD, Moores Cancer Center, University of California San Diego, told Medscape Medical News in an email.

"Our findings in this study — that palliative care reduces aggressive care at the end of life — complement clinical trial results and further stress the importance of early intervention with palliative care providers for oncology patients," he added.

Patients With Advanced Cancer

For the study, the team accessed the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database to evaluate the effect of a palliative care encounter on healthcare use at the end of life among 6580 Medicare participants with advanced cancer. Patients included in the analysis had advanced prostate, breast, lung or colorectal cancer.

End-of-life care included visits to the emergency department (ED), hospitalization, admission to the intensive care unit (ICU), and hospice care.

Chemotherapy or the initiation of a new chemotherapy agent and the need for invasive procedures (including venous catheterization, intubation, transfusion of blood products, thoracentesis, lung or liver biopsy, or cardiopulmonary resuscitation) were also counted as aggressive end-of-life interventions.

Researchers used an elaborate statistical method to arrive at 3290 matched pairs of patients (1 who had received a palliative care consult and 1 who had not).

"Overall, patients who received palliative care had increased use of most health-care services in the 30 days before consultation compared with the nonpalliative care group," the study authors report.

Table. Care Use 30 Days Before Palliative Care Consultation

Type of Care Palliative Care Consult (%) No Palliative Care Consult (%) Risk Ratio
>1 hospital admission 21.4 6.4 3.33
>14 d of hospitalization 14.5 6.8 2.12
>1 ED visit 18.8 7.6 2.47
ICU admission 25 15.1 1.66

 

In the 30 days before having a palliative care consult, patients were also 61% more likely to receive any chemotherapy than the nonexposed group, although they were 25% less likely to have a new chemotherapy regimen initiated than non–palliative care controls.

However, this pattern was reversed after the palliative care consult, wherein hospitalization rates, ED visits, ICU admissions, and the use of invasive procedures until the time of death were roughly half the rates observed in the non–palliative care group.

Patients who had had a palliative care encounter were also over half as likely to receive chemotherapy — and about one third less likely to be started on a new chemotherapy regimen — than those who had no such encounter.

"Earlier palliative care encounters were associated with greater reductions in chemotherapy use (P < .001), greater reductions in average hospitalization days (P < .05), and increased time enrolled in hospice (P < .001)," the researchers point out.

They also found that patients seen by a palliative care provider had higher rates of hospice enrollment and, on average, slightly longer hospice stays than the non–palliative care group.

Asked whether greater disease severity might explain the higher intervention rates before the palliative care consult seen in the palliative care group, Dr Murphy suggested that if the palliative group had been sicker than the non–palliative care group — as higher preconsult intervention rates would suggest — that would tend to bias the palliative group toward needing more interventions after the palliative consult as well.

That, however, clearly was not the case, suggesting that exposing patients to palliative care reduces aggressive end-of-life interventions compared with care in which no palliative care component is included.

Disturbing Trends

On the other hand, a disturbing trend emerged from this data set, suggesting that the timing of the palliative care consult came very late in the patients' disease course, with a median time from consultation to death of 12 days.

Furthermore, patients exposed to palliative care were more likely to be admitted to hospice within 3 days of their death than those who did not receive palliative care. "We suspect that the bump in hospice enrollment within 3 days of death likely stems from the lateness of palliative care consultation in our patient population," Dr Murphy said, "[even though] the benefits of hospice are greater for patients and caregivers when patients enroll earlier."

The fact that these Medicare beneficiaries received palliative care at such a late stage of their disease would not appear to be all that unusual. As Dr Murphy noted, prior research from their group involving a similar patient population indicated that approximately three quarters of all palliative care consultations take place in the last 4 weeks of life.

"Our current study found that early palliative care has the potential to result in a greater impact on patient patterns of healthcare delivery," Dr Murphy observed.

"[On the other hand], our study also demonstrates that we have yet to meet this goal in a substantial number of patients," he added.

Commenting on the study, Andrew Epstein, MD, an American Society of Clinical Oncology expert in palliative care, indicated that "the study provides even more evidence of the benefits of palliative care for patients with advanced cancer and the importance of integrating palliative care alongside standard oncologic care."

"It also complements the findings of other studies that providing palliative care to patients earlier translates into less intensive care, improved quality outcomes, and cost savings at the end of life for patients with cancer," Dr Epstein added.

The study was supported by the National Institutes of Health. Dr Murphy and Dr Epstein have disclosed no relevant financial relationships.

J Oncol Pract. Published online August 22, 2017. Abstract

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