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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 =
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
October Issue of IMpact