End-of-Life Care for Older Adults with Aggressive Non-Hodgkin Lymphoma
Authors: Markovitz Netana H. , Yi Alisha , Odejide Oreofe O. , Newcomb Richard , Amonoo Hermioni L. , Nelson Ashley M. , Reynolds Matthew J. , Rice Julia , Lavoie Mitchell W. , Nipp Ryan D. , El-Jawahri Areej , Johnson Patrick Connor Connor 
Published: November 2021

Abstract
Background: Aggressive non-Hodgkin lymphoma (NHL) commonly affects older adults and is often treated with intensive therapies. Receipt of intensive therapies and absence of a clear transition between the curative and palliative phases of treatment yield prognostic uncertainty and risk for poor end-of-life (EOL) outcomes. However, data regarding the EOL outcomes of this population are lacking.
Methods: We conducted a retrospective analysis of adults &gt;65 years with aggressive NHL treated with systemic therapy at Massachusetts General Hospital from 4/2000-7/2020 who subsequently died. We abstracted patient and clinical characteristics and EOL outcomes from the electronic health record (EHR), including patients' place of death, cause of death, palliative care and hospice utilization, and hospice length of stay using the EHR and the Social Security Death Index. We also determined whether patients were hospitalized (yes versus no), received systemic therapy (yes versus no), or were admitted to the ICU (yes versus no) within 30 days of death. Using multivariable logistic regression, we examined factors associated with hospitalization within 30 days of death and hospice utilization.
Results: Among 91 patients (median age = 75 years; 37.4% female), the most common lymphoma diagnosis was de novo DLBCL/grade 3B follicular lymphoma (64/91, 70.3%), and the majority (64/91, 70.3%) had advanced stage disease. Overall, 70.3% (64/91) were hospitalized, 34.1% (31/91) received systemic therapy, and 23.3% (21/90) had an intensive care unit admission within 30 days of death. The rates of palliative care consultation and hospice utilization were 47.7% (42/88) and 39.8% (35/88), respectively. A minority (21/88, 23.9%,) received palliative care more than 30 days before death. Of those receiving palliative care consultations, the majority (33/42, 78.6%) occurred exclusively in the inpatient setting, and most (32/42, 76.2%) were seen either as a one-time consultation or followed during a single inpatient hospitalization. Symptom management (24/42, 57.1%) was the most common reason for palliative care consultation, followed by both symptom management and goals of care (11/42, 26.2%) and goals of care (4/42, 9.5%). Only 39.8% (35/88) received hospice services, with 80.7% (71/88) having a hospice length of stay ≤ 7 days. Among hospice enrollees, the median length of stay on hospice was 7 days (range: 0-117). Among all patients, 51.6% (47/91) died in hospital, rehab, or nursing home, 23.1% (21/91) died at home, 11.0% (10/91) died in inpatient hospice or a hospice house, and 14.3% (13/91) had an unknown or other place of death. The most common cause of death was cancer progression (44/91, 48.4%,) followed by infection or cancer treatment complication (20/91, 22.0%). In multivariable analysis, elevated LDH was associated with risk of hospitalization within 30 days of death (OR 3.61, p=0.014). Palliative care consultation (OR 4.45, p=0.005) and hypoalbuminemia (OR 0.29, p=0.026) were associated with likelihood of hospice utilization.
Conclusions: Older adults with aggressive NHL often experience high health care utilization and infrequently utilize hospice care at the EOL. Our findings underscore the need for interventions to optimize the quality of EOL care for this population, and provide important data to guide informed decision-making and help inform future interventions aimed at improving the EOL care of this unique geriatric oncology population.

Disclosures
No relevant conflicts of interest to declare.