bluuebunny/crossref_metadata_2025_split huggingface dataset:
A description of cancer directed therapy within 14 days of death in a community cancer institute.
Authors: Newport Kristina , Holliday Rachel , McNaughton Caitlyn , Gehron Emily , Horst Michael , Sivendran Shanthi 
Published: November 2017

73 Background: It is recommend that no more than 10% of patients receive chemotherapy within 14 days of death. Aggressive end of life interventions like chemotherapy and hospitalization are used as measures of quality. However, cancer care now includes immunotherapy and targeted therapies. It is therefore important to understand how all cancer directed treatments are utilized at end of life, to better define the group of patients for whom they are indicated. Therefore, we sought to describe the people in our institution who received cancer directed therapy in the last two weeks of life. Methods: Adult patients who received cancer directed therapy for any malignancy in a single community cancer institute and died from July 2016-April 2017 were included. Retrospective data collection included clinical cancer stage and type, ECOG performance status (ECOG), last cancer therapy, date of death, dates of treatment, type of treatment, treatment goal, demographics and utilization of ED, hospital, palliative care and hospice. Results: A total of 218 patients were included. 13.7% (30/218) received cancer directed therapy within 14 days of death. Of those patients, only four had ECOG of 3, while 26 had ECOG 0-2. The average duration from treatment to death in this group was eight days, with one patient dying on the day of treatment. The average duration from treatment to death for all patients was 166 days (median 59). 20 patients receiving cancer directed therapy at end of life received chemotherapy, while the remaining 10 received targeted therapy (8) or immunotherapy (2). 40% (8/20) of patients in the chemotherapy group died in hospital as did 50% (5/10) of the remaining patients. Most patients in the overall sample (83%) were being treated with palliative intent. 20% (6/30) of the patients who died within 14 days of treatment were being treated with curative intent. Conclusions: Recommendations regarding cancer directed treatment near end of life need to include non-chemotherapy treatments such as immunotherapy and targeted treatments. Although a small sample size, our data suggest that patients on these treatments receive aggressive end of life care at a similar frequency as those who receive chemotherapy.
End-of-life (EOL) care in medical oncology fellows' clinics.
Authors: Liu Yang , Ramamurthy Chethan , Anari Fern , Varshavsky Asya , Martin James , Kasireddy Vineela , Goldrich Adam , Ghatalia Pooja , Gerson James , Smith Chad , Knollman Hayley Michelle , Tan Carlyn , Egleston Brian L. , Collins Molly , Dotan Efrat , Bauman Jessica Ruth 
Published: November 2017

75 Background: Medical oncology fellowship training presents a critical time for developing skills necessary for discussing end of life (EOL) care preferences with patients and delivering EOL care. There is little data exploring the delivery of EOL care by fellows in practice. We describe our fellows’ experience and identify areas to improve delivery of EOL care and communication. Methods: We retrospectively reviewed electronic medical records (EMR) of patients at our center with advanced (metastatic or recurrent) solid tumors who received care in fellows’ clinics and died between 7/1/2016 and 6/7/2017. We used Fisher’s exact test to determine associations between variables. Results: We included 103 patients from 46 distinct fellow clinics covered by 16 fellows. 54 (52%) were male; median age was 70 (37-94) years. 42 (40%) had a gastrointestinal malignancy, 31 (30%) had lung cancer. Median duration of advanced cancer was 12 (0.5-120) months. Patients received a median of 2 (1-10) lines of chemotherapy. 10 (10%) received chemotherapy within 14 days of death. 10 (10%) used outpatient palliative care (PC). 48 (47%) had EOL/hospice discussions in the outpatient clinic, while 10 (10%) had code status documented in a clinic encounter, and 20 (19%) had a copy of an advanced directive in the EMR. Median time from EOL discussion to death was 30 days (4-171). 69 (67%) enrolled in hospice and median length of stay on hospice was 18 days (1-142). 58 (56%) were hospitalized and 13 (13%) admitted to the ICU within 30 days of death. Of patients not enrolled in hospice, 8 (8%) died at home without hospice, 23 (22%) died in a hospital or ICU, 3 (3%) died in other or unknown places. Patients who had EOL discussions in clinic were more likely to enter hospice (p = .006) and less likely to be hospitalized (p = 0.016) within 30 days of death. Conclusions: Fellows at our center have significant exposure to outpatient EOL discussions and delivery of EOL care. EOL discussions in clinic were associated with decreased rates of health care utilization within 30 days of death. There were low rates of outpatient code status discussions and documentation of advanced directives, and few patients received outpatient PC, which represent potential areas to enhance fellow training and improve patient EOL care.
Equality during end-of-life cancer care: Trends in aggressiveness of cancer care at the end of life.
Authors: Namireddy Praveen , McLawhorn Vicki , Jonnalagadda Sweta , Muzaffar Mahvish 
Published: November 2017

77 Background: Aggressive cancer care at the end of life (EOL) can impact quality of life and have major economic burden. The purpose of this study was to portray the aggressiveness of EOL cancer care, and its relation to race, gender and social factors in Eastern North Carolina with high rural and minority population. Methods: This is a retrospective analysis of 401 stage 4 solid tumor patients who died between 2011 and 2014. Aggressiveness of care was calculated by a composite score adopted from Earle et al. Scores range from 0 to 7 with higher scores indicating more aggressive EOL care. 1 point was given to each indicator of aggressiveness in the last 30 days of life: ED visits ≥2,hospital admissions ≥2,any ICU admission,hospitalized days ≥14,new chemotherapy, hospice care ≤ 3 days, and any chemotherapy in the last 14 days. Results: Among the 401 patients, 217 (54%) were white and 178 (44%) were black. The mean composite score of aggressiveness (CSA) for whites was 1.18 and for blacks it was 1.87. (p<0.001).In the last 30 days of death, a higher proportion of blacks had ≥ 2 ED visits 28% vs 13%(p<.0001), ≥ 2 hospital admission 23% vs 13%(p=0.001), any ICU admission 29% vs 16%(p=0.0002), chemotherapy in the last 14 days 30% vs 20%(p=0.001), ≥ 14 hospitalized days 35% vs 21%(p<0.001), and hospital deaths 46% vs 32%(p=0.001) compared to whites. More whites enrolled in hospice compared to blacks 53% vs 45% (p<0.001). Correlation analysis using Fit Y by X model between CSA (score ≤ 3 and >3) and other variables showed statistically significant difference between whites vs blacks p <0.001, females vs males p=0.0006, not married vs married p<0.0001, and no family support vs family support p<0.0001. Conclusions: Male, unmarried and black patients were associated with higher CSA. Patients who were white, married and with family support had high likelihood of enrolling in hospice. [Table: see text]
Lessons from bereaved families: Insights about how the care of patients impacts bereavement.
Authors: Morris Sue Ellen , Block Susan 
Published: November 2017

87 Background: Feedback from bereaved families, including surveys of family members’ experiences during the patient’s illness and final days, can provide important insights into ways to improve the care of patients with advanced illness and their families. Methods: A convenience sample of 140 bereaved family members from Dana-Farber Cancer Institute (DFCI) completed a survey developed by the authors about their bereavement experiences. Families were asked to describe ways in which the clinical team was helpful in dealing with their loss; what they wished the clinical team had done prior to the death that would have helped in dealing with their loss; and actions taken by the team that were unhelpful or difficult for them in dealing with their loss. The Institutional Review Board at DFCI approved the study. Results: 67% of participants were female and 81% had lost a spouse or partner. The most common responses about ways in which the team was helpful in dealing with their loss included: showing compassion, sending condolence letters or making calls, and offering honest facts and information. Prior to the death of the patient, the most common response about what they wish the team had done was providing more realistic information about prognosis. When asked about actions that were unhelpful or difficult, only 24 responses were given with 50% of participants omitting this question and the remaining stating that there was nothing that the team did that was unhelpful. Of the 24 responses, the most common concerned a lack of contact or contact that was impersonal after the death. Conclusions: This survey demonstrated that families could provide input about ways clinicians can have a positive impact on the bereavement experience of families in caring for the patient before death. Compassion, accurate information, especially about prognosis, and contact with the clinician during early bereavement were highly valued by respondents. The most common unhelpful behavior identified was lack of personal contact following the death of the patient. Improved communication by the clinician, both before and after the patient’s death, has potential to improve the bereavement experience of family members.
Acute care medical interventions in the palliative care unit versus inpatient hospice.
Authors: Vidal Marieberta 
Published: November 2017

88 Background: In a survey of different cancer centers in the United States, only 23% reported having dedicated palliative care beds and hospital executives have reported not having further plans for expansion of their program. Barriers that are often cited include poor reimbursement for services, limited institutional support and resources. Patients admitted to an Acute Palliative care unit (APCU) benefit from the multidisciplinary approach that is evident in daily rounds, interdisciplinary team meetings, and family conferences. There could be occasionally misconceptions about the differences between inpatient hospice and an APCU. Even though the psychosocial component of palliative care is extremely important a significant amount of medical interventions also are necessary to provide patients and family with a sense of and optimal care during this time. Methods: A retrospective chart reviewed was performed in 100 consecutives patients admitted to the APCU and inpatient hospice prior to October 2013. From this data we identified the acute medical interventions ordered by the palliative Care specialist tduring the first 5 days of admission. Results: A total of 100 patients from the APCU and 100 patients from inpatient hospice were reviewed. In the APCU 100% of patients had iv fluids vs 7% in inpatient hospice. Antibiotics were given in 52% of APCU patients vs 2% in the inpatient hospice. Steroids were given in 48% of APCU patients vs 30% in inpatient hospices. (See Table). Conclusions: The APCU in comparison to inpatient hospices had higher rate of acute medical interventions with the most common been iv fluids, antibiotics, laboratory and radiologic diagnostic tests. This represent the importance of Acute Palliative Care Units in advanced cancer patients with complicated situations to achieve comfort when transitioning to EOL. [Table: see text]
Acceptability and effects of values-based outpatient advance care planning (ACP) in gastrointestinal (GI) cancers.
Authors: Epstein Andrew S. , O'Reilly Eileen Mary , Volandes Angelo E. , Shuk Elyse , Romano Danielle R. , Breitbart William 
Published: November 2017

9 Background: We developed and validated the values questions for the Person-Centered Oncologic Care and Choices (P-COCC) ACP intervention, which combines an informational care goals video with a patient values interview. Herein, we studied (primarily) the acceptability of P-COCC, and (secondarily) its effects on wellbeing and decisional conflict. Methods: Patients (pts): English-speaking with GI cancer, ≤ monthly followup in MSK medical oncology clinics and believed by their oncologist able to complete study measures and survive 1-12 months. Consented pts randomized 2:2:1 to P-COCC vs. video alone (V) vs. usual care (UC). Questionnaires: administered baseline and at next follow-up visit on validated measures of wellbeing, and on follow-up only, decisional conflict. P-COCC arm pts also completed 3 Likert scales (was the intervention helpful, comfortable and recommended to others?); a positive score on ≥1 of 3 indicated acceptability for that pt. Results: During screening from 9/2014-11/2016, 202 pts were approached. 51 (25%) declined participation (most common reason, N = 31 = not wanting to discuss the topic). 151 consented and were randomized; 99 (66% of the 151) completed study measures (most common attrition reason, N = 34 = disease progression or death). Of the 99, 63% male; mean age 61 years; mean ECOG PS 1; most common cancers colorectal, gastroesophageal, and pancreatic. The primary aim was met: Among 33 pts, 32 (97%, 95%CI: 0.84-0.99, p < 0.001) rated P-COCC acceptable. Mean distress scores (0-10) increased (0.43) in the P-COCC arm but decreased in the V (-0.04) and UC (-0.21) arms (p = 0.03 and 0.04, P-COCC vs V and UC, respectively). There were no significant pre-post change scores on other measures of wellbeing (anxiety, depression, stress, acceptance, QOL), or intergroup differences in decisional conflict. Qualitatively, P-COCC interviews revealed pt concerns, and desires for support and QOL. Conclusions: Our values-based ACP paradigm is acceptable but may increase distress in GI cancer outpatients. Further studies are investigating underpinnings and follow-up duration of these results, and ways to best support cancer patients (with any cancers, and regardless of prognosis) in ACP. Clinical trial information: NCT01912131.
Prospective assessment of symptom burden interfering with decision making during the end-of-life phase of high-grade glioma patients.
Authors: Walbert Tobias , Schultz Lonnie , Phillips Joel 
Published: November 2017

90 Background: To date it is unclear when patients with high grade glioma (HGG) lose their capacity to make decisions during the end-of-life (EoL) phase. EoL symptoms have not been prospectively assessed. The goal of this prospective single center study was to assess the symptom burden in terminal HGG patients with a special focus on symptoms related to decision making capacity during the last 3 months of life. Methods: Patients with HGG, failing 3rd line therapy, showing clinical and/or radiological progression with a Karnofsky Performance Status score < 60 were eligible for enrollment. A baseline MD Anderson Symptom Inventory Brain Tumor Module (MDASI-BT) was performed upon enrollment. Patients or surrogates received bi-weekly telephone calls to repeat the MDASI-BT. Calls continued until death, or refusal to participate. Symptoms were stratified by weeks prior to death. Mixed models were used to assess for symptom and interference changes over time. Overall time effect was tested at the 0.05 level. If significant, pairwise comparisons of the time groups were done. Testing level was set at 0.01 to take into account the large number of comparisons. Results: Symptom scores of 52 patients are available for analysis. Symptoms involved in decision making such as speaking, concentrating, drowsiness (all p < 0.001), and understanding (p < 0.011) started to decline severely 12 weeks prior to death. The cognitive construct (understanding, remembering, speaking, concentrating) was significantly impaired during the last 2 weeks of life and started to deteriorate after week 12 (p < 0.001). The decision making composite score (understanding, speaking, concentrating, fatigue, drowsiness) showed the same pattern (p < 0.001). Overall disease burden also significantly increases within the last 2 weeks of death. Conclusions: Patients with HGG have a high symptom burden during the active EoL phase, increasing significantly during the last 12 weeks prior to death. Symptoms interfering with decision making capacity increase after week 12 and reach their peak 2 weeks prior to death. These findings stress the importance of early initiation of palliative care and advance care planning in patients with HGG.
Impact of palliative care rotation on gynecologic oncology fellows' knowledge, rates of explicit teaching, and perceived competence in palliative care.
Authors: Lefkowits Carolyn , Tamber Anoo , Leahy Janet , Teuteberg Winifred 
Published: November 2017

95 Background: Impact of a PC rotation on fellows in the primarily surgical specialty of Gynecologic Oncology (GO) has not been described. We aimed to evaluate the impact of a month-long PC rotation on GO fellows’ knowledge, exposure to explicit teaching and perceived competence in PC. Methods: Four years of GO fellows (n = 8) were surveyed before and immediately after a month-long PC rotation about knowledge, explicit teaching and perceived competence across four domains - pain management, non-pain symptom management, out of hospital care and communication/ethics. Knowledge was assessed via 30 multiple choice questions (MCQ). Perceived competence to address 25 PC topics was assessed on a Likert scale (1 to 5). Participants were asked about explicit teaching of 21 PC topics before and during the rotation. The rotation included 5 clinical settings and 7 dedicated didactic strategies beyond routine participation in clinical care. We used medians tests to compare total correct items pre vs post rotation, paired differences pre to post of perceived competence and paired differences pre to during rotation rates of explicit teaching of PC topics. Results: Post-rotation, participants demonstrated significant improvement in knowledge (median MCQ percent correct pre 62% v post 67%; p = 0.01), explicit teaching (median percent items explicitly taught pre 19% v post 91%; p = 0.02) and perceived competence (median percent items competent or better pre 34% v post 100%; p = 0.01). The most highly rated clinical settings were inpatient hospice and inpatient PC consult service. The most highly rated didactic strategies were direct observation of communication skills practice and 10 minute didactics. The educational value of the overall rotation was rated as superior by 100% of participants. Conclusions: After a month-long PC rotation, GO fellows demonstrated significant improvement in knowledge, rates of explicit teaching and perceived competence in PC across all domains examined. Routine incorporation of a dedicated PC rotation should be considered for all gynecologic oncology fellows.
A grounded theory analysis of oncology nurses' perceptions of early palliative care in the context of ambulatory care.
Authors: Mohammed Shan Darrel , Savage Pamela , Zimmermann Camilla 
Published: November 2017

96 Background: In early palliative care (EPC), palliative supports and resources are provided at an earlier stage in the treatment trajectory. As major care providers, nurses play a pivotal role in ensuring the success of EPC as an emerging model of care delivery. In this study, we examine nurses’ perceptions of EPC in the context of ambulatory oncology care and explore how EPC fits within the broader professional mandate of nursing. Methods: We recruited nurses from several ambulatory care oncology clinics in a tertiary cancer hospital in Ontario, Canada. Nurses participated in semi-structured interviews seeking to qualitatively examine their attitudes and perceptions about EPC. Constructivist grounded theory guided our methods and analysis. Results: A total of 20 nurses that included six staff nurses, ten nurse practitioners, and four advanced practice nurses completed interviews. Participants worked in a variety of clinic settings such as breast, pancreatic, head and neck, and hematology. The core category Perceiving EPC as Synonymous with Fundamental Nursing Care encompasses three subcategories: (1) Prioritizing immediate care needs – recognizing the need for EPC to manage immediate pain and symptom management concerns; (2) Care coordination – viewing EPC as linking resources and organizing interprofessional care; and (3) Safeguarding and preventative care – initiating EPC to protect against difficult transitions between phases of treatment and to prevent being unprepared for active dying. Conclusions: This was the first study to qualitatively examine nurses’ perception of EPC. Nurses not only recognize the value of EPC to ensure good quality care for patients with cancer and their families, but also perceive this care as deeply embedded within the core values of nursing. Recognizing how nurses view EPC has implications for expanding the professional scope of nursing in palliative care and for preparing nurses for the complexities of this work.
Development of a telemedicine palliative care program in a cancer center.
Authors: Kim Youngho Paul , Saldivar Reggie , Sidlow Robert 
Published: November 2017

99 Background: Inpatient palliative care (PC) teams have increased their presence over the past decade, with over 90% of hospitals having access to PC specialists. However, such growth has not been mirrored in the outpatient setting; this is relevant for patients living far from major medical centers. Memorial Sloan Kettering Cancer Center (MSK) has expanded its ambulatory care footprint beyond New York City (NYC) to sites where PC is not currently available. To address the need for PC delivery to a geographically dispersed patient population, we developed a clinical initiative utilizing telemedicine technology. Methods: The Telemedicine Palliative Care Program (TPCP) was initiated after planning with multiple stakeholders, including clinical, legal, billing, compliance, ambulatory care, information systems, and scheduling departments. The TPCP provides PC consultation and management of patients via a “hub-and-spoke” model, whereby PC specialists are located at the main campus in NYC and patients are scheduled to be seen at one of six regional ambulatory cancer sites within a 50-mile radius. Regional ambulatory sites have video teleconference rooms equipped with Cisco (San Jose, CA) TelePresence MX300 hardware and Jabber software allowing for secure, high fidelity, real-time video communication with clinicians at the main campus who use iPads installed with Jabber software during their consultation sessions. Results: The TPCP is currently active at two regional sites in New York and New Jersey. Patient satisfaction, perception of quality of care, and patient outcomes will be measured. Preliminary results indicate that both patients and providers find this clinical program to be an extremely valuable experience. Conclusions: The technologic infrastructure is now available to deliver telemedicine-enabled PC for cancer patients in a geographically distributed model. Our early experience suggests that our program will help enable the convenient delivery of concurrent PC to cancer patients across a wide geographic area. This innovative clinical initiative has the potential to enable all MSK patients to access high-quality palliative care in a geography-agnostic manner, and eventually deliver such care to patients in their homes.