bluuebunny/crossref_metadata_2025_split huggingface dataset:
Assessing and acting on distress in oncology patients.
Authors: Zerillo Jessica A. , Nahas Myrna Rita , Schnipper Hester Hill , Rosenblatt Laurie , Dowling Holly , Sternberg Scot , Drews Reed , Savarese Diane M. F. 
Published: February 2017

89 Background: The American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) set a benchmark that 75% of cancer patients have emotional well-being assessed by the second visit. However, clinicians poorly assess and document emotional well-being. Methods: Our aim was to increase the documented assessment of emotional well-being in an academic medical center's Hematology/Oncology clinic to 75% or greater through a pre/post intervention study design. In fall 2012, clinicians collected baseline QOPI data from the first two visits of a sample of patients with newly diagnosed breast, non-small cell lung and colorectal cancers. Oncology social work and psychiatry implemented the NCCN Distress Thermometer in May 2013. At every provider visit, patients' distress scores were transcribed into a structured field in the electronic record. In spring 2014, clinicians collected post-intervention data. Results: All data used was collected through the routine QOPI chart abstraction process. 142 charts in fall 2012, and 55 charts in spring 2014 met criteria for pre/post assessment, respectively. There was a significant improvement in the assessment of distress (78.2% vs. 64.1%, p=0.01) and in the identification of distress presence (46.5% vs. 27.5%, p=0.01). However, there was better documentation for a plan of action for distress before the intervention (80% vs. 55%, p=0.02). Conclusions: The NCCN Distress Thermometer improved assessment and identification of distress. However, an action plan specifically addressing distress was significantly worse after implementation of the tool. Possible explanations include lack of documentation even if an action was implemented, lack of specificity of the tool to identify the source of the patient's distress so that a therapeutic plan could be targeted, or a failure of the clinician to appreciate the distress score as a valid measure. Further data are needed in order to understand the barriers for clinician documentation of action on patient distress. [Table: see text]
The impact of hospice services in the care of patients with advanced stage non-small cell lung cancer.
Authors: Hildebrand Sara , Tayapongsak Kristy , Stephenson Richard , Streer Nathan Paul 
Published: February 2017

104 Background: Prior research has shown that early incorporation of palliative care alongside standard oncological care in metastatic non-small cell lung cancer (NSCLC) patients results in longer survival and less aggressive treatment at the end of life. The purpose of our study was to profile the continuum of care of stage IV NSCLC patients, comparing it to quality indicators for excellence in end-of-life (EOL) cancer care, as defined by the Quality Oncology Practice Initiative and other published studies. Specifically, our aim was to explore the connection between hospice enrollment and end-of-life quality measures. Methods: 197 deceased stage IV NSCLC patients diagnosed between 2008 and 2010 at two separate tertiary care centers within the same county were identified. A retrospective review was conducted, collecting data from electronic medical records regarding antitumor treatment services received, post-diagnosis hospital admissions, palliative care consultations, hospice referrals and enrollments, and circumstances surrounding the patient’s death. The patients were separated into two groups depending on their status of hospice enrollment, and the remainder of the measures compared accordingly. Results: There was no significant difference in number of lines of chemotherapy received and total number of post-diagnosis hospital admissions between the patients who were enrolled in hospice and those who were not. However, the group who received hospice services had a significantly lower number of hospitalizations in the last 30 days of life (p<0.001), emergency department admissions in the last 30 days of life (p<0.01), and intensive care unit admissions in the last 30 days of life (p<0.001). Median survival, measured by the length of time between diagnosis and death, did not differ between the two groups. Conclusions: This study demonstrates that, among patients with metastatic NSCLC, hospice enrollment was associated with optimized end-of-life oncological care, as seen with fewer hospital admissions in the last 30 days of life, without incurring a lower median survival.
Treatment preference discussion in oncology outpatient clinic.
Authors: Nasir Syed Sameer , Ul Haq Mansoor , Pandey Manjari , Ogbeide Osarenren , Ogbata Obiageli Uchenna , Dill Drew Sterling , Ryder Katheryn M , Weir Alva Bowen 
Published: February 2017

106 Background: Often end of life discussions are either not held in a timely manner or remain poorly communicated when outpatients are transferred to hospital care. This leads to unwarranted and costly interventions. Methods: In an academic oncology clinic we developed an electronic medical record (EMR) template that listed important information for management decisions, including life expectancy, goals of management and specific patient treatment preferences (ventilator support, tube feedings, transfusions, do-not-resuscitate (DNR) wishes, etc.). The completed note was placed in an easily retrievable location in patients’ electronic charts. Clinic charts were reviewed one week ahead of visits to identify patients who were within the last year of life and a pop up reminder for the treating physician was placed in the EMR. The physicians who admitted our patients to the hospital were educated on utilization of the template notice. We compared the percentage of patients with advanced directives or treatment preference notes before the intervention with the percentage 1½ years after the intervention was begun. We utilized a cross-sectional, self-administered survey to compare in-patient physician responses before and after implementation of the intervention to evaluate the in-hospital utility of the intervention. Results: Easily accessible treatment preference or advanced directive discussions with patients in their last year of life increased from 32% to 55% (p =0.004) with the intervention. Results of the survey also showed improved understanding of patient’s wishes for DNR status (26.9% vs 52.6%, p = 0.08) among admitting physicians. Conclusions: The development of an easily utilized EMR template to record the treatment preferences of patients near the end of life, with an EMR accountability instrument, improved both documentation of discussion and physician understanding of patient treatment preferences when patients were transferred from outpatient to inpatient care. We hypothesize that this intervention will lead to a decline in costly and unwanted interventions for patients near the end of life, and plan to test this hypothesis with further outcomes measures.
“It’s about the conversation”: A multidisciplinary intervention to support advance-care planning.
Authors: Zachariah Finly , Klein Linda , Clifton-Hawkins Nancy , Andrews Becky , McQueary Andrea , Dillard Gaby , Gross Dawn 
Published: February 2017

111 Background: A recent California Healthcare Foundation study found that 60% of Californians highly valued “making sure their families are not burdened by tough decisions about their care." However, less than 50% have communicated their end-of-life wishes to their surrogate decision maker. 82% say it is important to have end-of-life wishes in writing, but only 23% say they have done so. At City of Hope National Cancer Medical Center (COH) the advance directive (AD) completion rate is less than 15%. The Department of Supportive Care Medicine Sheri & Les Biller Patient and Family Resource Center (BRC) is leading development of innovative strategies to foster Advance Care Planning (ACP) communication and documentation. Methods: A multi-specialty physician and interdisciplinary team assembled and designed a social media advertised 4-hour interactive event that was held in the BRC. Over 40 staff and volunteers facilitated individualized ACP conversations with the “Go Wish” cards, private consultations with social workers, showed novel COH ACP videos, provided multi-lingual ACP literature and advance directive documents available for completion with Notary support on-site. Results: Over 300 people attended, including patients, caregivers and COH staff. Forty-seven advance directives were completed (24 by patient/caregivers, 23 by COH staff). Twenty-nine Go Wish games were facilitated (2 in Spanish). Of the 52 attendees who completed exit evaluations, 44% were patients, 31% staff, and 11% were caregivers. Respondents reported that the event increased their comfort and likelihood of having conversations about ACP with others. Importantly, 38 of the 52 surveyed, did not have an AD prior to attending the event. Of those 38 attendees, 18 of them completed an AD at the event (or 47%). Conclusions: Advanced care planning is an all too often avoided conversation that results in increased distress of patients, families and providers. By proactively designing opportunities for facilitated conversations in dynamic and public arenas, fear and stigmas are diffused and the true focus and intent of discovering what people wish so the medical team, surrogates and family can ensure their values are honored and met become possible.
A prospective assessment of polypharmacy in the palliative care setting.
Authors: McNeil Michael Joseph , Kamal Arif , Ritchie Christine , Kutner Jean , Abernethy Amy Pickar 
Published: February 2017

112 Background: The number of prescribed medications increases substantially in the last year of life aggravating the risk of polypharmacy, adverse reactions and medication non-adherence. What medications do patients with life-limiting illness take? Methods: This was a pre-specified secondary analysis of data from a prospective trial. Eligible participants were adults with a <1-year prognosis taking a statin medication for primary or secondary prevention. Participants were enrolled from 15 sites, randomized to continue or discontinue statin medications, and followed for up to a year. Concomitant medications were recorded at least monthly. For participants with a primary diagnosis of cancer receiving care and with medication data available, prescribed medications were categorized according to the World Health Organization’s (WHO) ‘Guidelines for ATC Classification’ by class and sub-class. An expert panel of palliative care, oncology, geriatrics, and primary care physicians guided categorization. Descriptive statistics were calculated. Results: On average, participants (N=127) were 70 years old (SD 10) and lived 216 days (SD 123) on study; 69% had metastases, 23% had cancer without metastases, 7% had lymphoma, and 1 had leukemia. In total, 49 classes, 156 sub-classes and 283 different medications were prescribed. The five most commonly prescribed medications were: anti-hypertensives, strong opioids, laxatives, gastric protection aids, and anti-emetics. Only 1.2% of medications prescribed were chemotherapy or antineoplastics. Patients took an average of 10.7 (SD 5) number of medications at the time of enrollment and 10.0 (SD 5) medications at death or termination of the study. 31% of patients were on 15 or more medications at any time during the study. Conclusions: Polypharmacy, defined as >10 medicines, is common in the last year of life for people with cancer. Patients commonly receive supportive care medications and drugs for comorbidities like hypertension; antineoplastics are rare. Thoughtful approaches to medication simplification in the palliative care setting are needed.
Targeted therapy at the end of life and the impact on health care utilization.
Authors: Yeung Heidi , Salehi Parsa , Murphy James Don 
Published: February 2017

116 Background: The use of targeted therapy has steadily increased over the past decade, though the impact of targeted agents on patterns of care at the end-of-life life remains unknown. The purpose of this study was to explore the influence of targeted therapy on end-of-life care in a large population-based database. Methods: We identified 14,398 patients from the SEER-Medicare linked database with metastatic breast, lung, or colorectal cancer diagnosed between 2000 and 2009 who received conventional cytotoxic chemotherapy or targeted therapy in the last 3 months of life. Multivariate logistic and linear regression models were used to determine the impact of targeted therapy on the following endpoints in the last 3 months of life: emergency department (ED) visits, hospitalizations, and hospice utilization. Analyses were adjusted for differences in patient age, gender, race, comorbidity, socioeconomic status, and geography. Results: Among the whole study cohort 83% of patients received chemotherapy alone, 12% received chemotherapy with targeted therapy, and 5% received targeted therapy alone. The delivery of any targeted therapy in the last 3 months increased across the study period, from 1.5% in 2000 to 28% in 2009. Compared to patients treated with chemotherapy alone, those treated with targeted therapy alone had lower rates of ED visits (adjusted odds ratio [aOR]=0.81, p=0.01), lower rates of hospitalization (adjusted odds ratio [aOR]=0.69, p<0.0001), no difference in overall hospice utilization rates, though had longer stays on hospice (5.1 days longer, p<0.0001). Compared to patients treated with chemotherapy alone, those treated with both chemotherapy and targeted therapy had no difference in ED visits or hospitalization admission rates, though had decreased rates of hospice utilization (aOR = 0.79, p<0.0001), and shorter stays on hospice (2.7 days longer, p<0.0001). Conclusions: This study found that targeted therapy was associated with varying patterns of healthcare utilization at the end-of-life, though these differences could be influenced by unknown confounding variables. Future research should focus on defining the specific impact of targeted therapy on quality of life at the end-of-life.
Early versus late referral to hospice care: A case-control study.
Authors: Voisine Michael , Dahiya Saurabh , Besharatian Behdad , Friderici Jennifer , Stewart James A. 
Published: February 2017

127 Background: Hospice care can improve quality of life (QOL) for patients with advanced cancer. Studies suggest that hospice services are offered late in the course of terminal illness; limiting patient comfort and QOL. Limited literature exists on barriers to timely hospice referral. We examined demographic and clinical characteristics associated with late hospice referral. We hypothesized that age, malignancy type, and performance status (PS) may predict late referral to hospice. Methods: Patients were age 18+ cared for by oncologists of Baystate Medical Practices, referred to Baystate Hospice from 1/1/08 to 12/31/2010. Demographics and diagnosis (e.g., breast, lung, GI) were abstracted from the electronic medical record. Referral interval was calculated as date of death minus date of referral. Late referrals (“cases”) were classified as interval quintiles 1 and 2; early referrals (“controls”) quintiles 4 and 5. Fisher’s exact test and Wilcoxon Rank Sum identified demographic and clinical characteristics associated with late referral. Multivariable logistic regression was used to identify independent predictors of late referral. Results: 209 patients met inclusion criteria. The median referral interval was 29 days (IQR 12, 57). In the multivariable model, ECOG score (OR 1.51 95% CI 1.09 2.08); dementia (OR 0.08, 95% CI 0.01, 0.82); CNS cancer (OR 0.14, 95% CI 0.03, 0.73); and unclassified cancer (OR 0.32, 95% CI 0.14, 0.73) independently predicted late referral. Age, race, and sex were not associated in uni- or multivariable comparisons. Conclusions: In this study of 209 patients with advanced cancer enrolled to hospice, malignancy type, dementia, and performance status are associated with late hospice referral. We believe it is important to track timing of referral and look for ways to reduce barriers.
Use of targeted therapy in cancer patients in the end-of-life period.
Authors: Wann Alysson , Ashley David M. , Khasraw Mustafa 
Published: February 2017

129 Background: There is limited data on the use of these targeted therapies in patients at the end of life. This study reviews the pattern of use of targeted and potentially futile, toxic and costly therapies at the end of life at an Australian cancer centre. Methods: A retrospective single-centre review covering 12 month period of patients who died < 3 months of starting a targeted agent. We extracted demographics, types of cancers, types of therapy, median age and lines of prior therapy. Results: 478 patients were on targeted therapies during this period. 54 patients, (11.3%) died < 3 months. Of those, the median age was 69 years, men 65%, women 35%. 27 had haematological malignancies (mostly lymphoma and multiple myeloma), 21 had solid tumours (mostly colon and lung cancer). Ten agents were represented with erlotinib, bevacizumab, and rituximab having higher total number of deaths and none on transtuzumab. Treatment lines were first in 64.8%, second in 20.4% and 14.8% had > 2 lines of treatment. Performance status was only documented in 9.3% at start and 11.1% at end of treatment. Symptoms at the start of treatment that can be used to track improvement were only documented in 25 patients (46.3%). Gender, type of cancer, age was found to have no influence on death < 3 months of targeted treatment. Unfortunately we were unable to extract QoL data. Conclusions: In this small single centre descriptive study, the use of targeted therapy in the end of life population was common, mostly in first line treatment. No factors have shown correlation with dying < 3 months of targeted therapies. There is a need to better document performance status and QoL data and also to analyse indicators of when it is appropriate to cease targeted therapies.
Characteristics of patients referred to a community-based palliative care consultation service.
Authors: Alvarez Adriana L. , Samala Renato Verayo , Gupta Mona , Rybicki Lisa A. 
Published: February 2017

132 Background: Home-based palliative care programs by multi-disciplinary providers improve patient and caregiver satisfaction, enhance symptom control, increase hospice use, and decrease acute care encounters. We launched a community-based consultation service to deliver high-quality palliative care to patients who are homebound or staying in various post-acute care facilities. The study described the characteristics of our patients, and determined the relationship between certain demographic features and outcomes. Methods: We conducted a restrospective chart review of patients seen on initial consultation and subsequent visits between January 1, 2011 and December 31, 2011. All patient encounters were done by 4 palliative care physicians. Data pertaining to demographics, diagnosis, hospice use, and death were obtained and analyzed. Results: A total of 221 patients were evaluated. The median age was 75 years, 61.1% were female, 51.1% had cancer, 79.1% were seen at home, and 57% possessed advance directives at initial consultation. Almost half (45.2%) of the referrals were made by primary care physicians. Majority (82.4%) of the referrals were for symptom management, while 37.6% were for goals of care discussion. Many patients had several reasons for consultation, as well as multiple symptoms, such as pain (65%), fatigue (54.8%), and dyspnea (22.6%). The mean number of follow-up visits was 0.62 + 1.08. During the study period, 33.5% of patients died, and 42.5% enrolled in hospice. Of the deaths, 48.7% occurred within 30 days of initial consultation, and 50.0% died at home. Age, gender, race and marital status were not related to hospice enrollment, death, and time and site of death. Patients with advance directives were more likely to enroll in hospice (50.0% vs 32.2%, p=0.009), while those seen at home were more likely to die at home rather than in a facility or hospital (61.0% vs 16.9% vs 22.0%, p<0.001). Conclusions: Patients referred to our community-based palliative care consultation service were mostly homebound older adults needing symptom management and goals of care discussion. Our program may have been helpful in providing quality end-of-life care by facilitating hospice enrollment and death at home.
Exploring the palliative care needs of Hispanic immigrant mothers with advanced cancer.
Authors: Saldana Rafael Alonso , Park Eliza , Check Devon , Reeder-Hayes Katherine Elizabeth , Mayer Deborah 
Published: February 2017

135 Background: Hispanics are the fastest growing demographic group in the United States and cancer is the leading cause of death in this population. Hispanic immigrants encounter a number of challenges when confronting end-of-life care: geographical and cultural separation from families; language and educational barriers; fear of discrimination; and in the case of undocumented immigrants, fear of deportation. The experiences of Hispanic patients with advanced cancer who are parents of dependent-age children are essentially unknown. Therefore, we used qualitative methods to identify the palliative care and end-of-life needs of this unique population. Methods: We recruited five Spanish-speaking, Hispanic mothers with metastatic cancer to complete a semi-structured interview about their experiences. The interviews addressed coping with advanced illness, sources of distress, parenting changes, medical decision-making strategies, and communication about illness. Data were analyzed using traditional content analysis techniques. Results: Participants were all female, ages 34-43 year old. On average, they had 3.4 children and 8.2 years of education. Common themes were: (1) the financial burden of cancer; (2) low social support for parenting and household responsibilities; (3) lack of perceived role in medical decision-making; (4) and religion as primary source of coping and hope. We also identified several communication barriers in conducting a palliative care study with this population. Conclusions: Future palliative care studies can improve Spanish-speaking Hispanics’ comprehension by incorporating Spanish vocabulary into the interviews and providing greater explanation of concepts such as shared decision-making, cancer staging, palliative care, and hospice. Greater awareness of financial concerns and insufficient social support may help oncology providers and researchers develop interventions to help Hispanic parents with advanced cancer. Further studies are needed to learn more about the unmet needs of end-of-life care for this demographic group.