Addressing spirituality within serious illness is a core dimension of palliative care delivery. However, spiritual care frequently lacks integration within the care of patients and families facing serious illness. This chapter discusses the integration of spiritual care into palliative care delivery. Requisite to this integration is a clear understanding of definitions and palliative care guidelines informing spiritual care provision. Furthermore, integration is informed and motivated by a large body of evidence showing how spiritual and religious factors frequently play salient roles in serious illness and influence palliative care outcomes. The integration of spiritual care into palliative care practice relies on a generalist–specialist model, within which all members of the interdisciplinary palliative care team are responsible for spiritual care provision. Non-spiritual care specialist members of the palliative care team are responsible for generalist spiritual care delivery, including taking spiritual histories and screening for spiritual needs. The care team also includes spiritual care specialists, typically board-certified chaplains, who provide in-depth spiritual care delivery to patients and families and aid the care team in understanding the spiritual and religious dimensions of care. Additionally, data regarding tested spiritual care interventions are discussed as potential tools palliative care teams can employ to improve patient care and outcomes. Finally, the integration of spiritual care into palliative care teams presents both opportunities and challenges that must be considered as efforts needed to foster more seamless spiritual care delivery within palliative care.
123 Background: Radiation is often used to palliate symptoms in patients with advanced cancer and the number of fractions used can vary significantly from as short as a single fraction (SF) to up to a multiple week course. No data currently exists regarding demographic factors and their influence on survival and fractionation decisions. The aim of this project is to investigate the association of demographic factors with survival, likelihood of SF use in patients (pts) receiving RT for bone metastases, and likelihood of hypofractionation (HF) (≤ 5 fx) in pts being treated for any palliative reason, excluding those receiving partial brain RT (PBRT) which includes stereotactic radiosurgery, and stereotactic radiation therapy. Methods: We retrospectively reviewed charts of pts treated with palliative RT between 1/2015 – 5/2017 at 2 tertiary centers and 4 community satellite practices. Demographic factors analyzed are included in table 1. Logistic regression was used to evaluate the associations between the factors and outcomes. Results: A total of 928 pts were included in the survival analysis. In the two subset analyses, 373 pts were included in the bone metastasis analysis and 745 were included in the analysis of all patients excluding pts receiving PBRT. In pts treated for bone metastases, consult type (inpatient vs. outpatient) was the only significant factor on multivariate analysis, with inpatient consults being more likely to get SF (HR = 2.169, =.025). In the pts receiving palliative RT (excluding PBRT), race and consult location (tertiary vs. community) were significant. Non-white pts (HR=0.527, p=.012) and pts treated in the community (HR=.778, p<.001) were less likely to get HF. Gender (male vs. female), consult location (tertiary vs. community), and consult type (inpatient vs. outpatient) were significant on multivariate analysis for survival (HR=1.243, p=.028; HR=1.602, p<.001; HR=2.301, p<.001, respectively). Conclusions: This analysis suggests that demographic factors may affect both survival and decision making regarding fractionation in patients receiving palliative radiation. Further investigation into the reasons for these differences is needed.
128 Background: The TEACHH model was previously developed to predict life expectancy in patients with metastatic cancer receiving palliative radiation. However, the model was developed prior to the immunotherapy era and limited in its clinical utility due to broad ranges of survival in each prognostic group. The aim of this project is to refine the TEACHH model to improve its clinical utility in a modern cohort. Methods: We retrospectively reviewed the charts of patients seen in consultation for palliative radiation at two tertiary centers and 4 community satellite practices from 7/1/2015 – 12/31/2016. Cox proportional hazards regression was used to construct a prediction model for overall survival (OS), with a goal of predicting the probability of surviving to the clinically relevant timepoints of 2 months, 6 months, and 1 year. The model was stratified by consult location (tertiary vs. community). Results: A total of 744 patients were included in this analysis. The final model included: 1) Gender (Male HR 1.35, 95% CI 1.11 – 1.64) 2) ECOG PS (ECOG 1 HR 1.63, 95% CI 1.20 – 2.22, ECOG 2 HR 2.59, 95% CI 1.86 – 3.60, ECOG 3/4 HR 4.12, 95% CI 2.84 – 5.98) 3) Consultation type (Inpatient HR 1.87, 95% CI 1.40 – 2.49) 4) Primary histology 5) Number of metastases 6) Number of prior palliative chemotherapy courses. Due to interactions between primary histology and number of metastases as well as primary histology and number of prior palliative chemotherapy courses, hazard ratios for these variables are shown in Table 1. Conclusions: Our final refined TEACHH model includes 6 variables to predict OS. We hypothesize that its increased complexity will increase its sensitivity and we will validate the model in a separate patient cohort. A web-based calculator will then be created to facilitate easy use of the model. Hazard ratios of variables with significant interactions. [Table: see text]
135 Background: Palliative radiation therapy(PRT)is often employed in patients with advanced cancers requiring urgent consultation given the rapidity of presentation.We report on characteristics of urgent palliative oncologic issues encountered by radiation oncologists(RO). Methods: We prospectively evaluated patterns of presentation in162 consecutive consultations for urgent PRT at 3 centers from 5/19/14 to 9/26/14.Survey of palliative care issues was completed by physicians/nurse practitioners including assessment of reasons for urgent radiation oncology consultation,disease presentation characteristics and site of RT delivery.Response rate was 86% with 140 of 162 responses received. Results: Median age of patients was 63 years(29-89)with 39% > 65, 41% from 50-65 and 20% < 50 years;56% were males and 44% females. Most were married(62%)and 30% non-Caucasians.48% had ECOG PS 0-1,whereas it was 2, 3 and 4 in 24%,9% and 3%.Primary cancer diagnoses were lung (28%),breast(13%),prostate(10%),melanoma(10%),sarcoma(7%) and other diagnoses in 32%.Pain was predominant reason for consult(57%)followed by brain metastases(29%),spinal cord/cauda compression (13%),dyspnea (10%),bleeding (8%),bone fracture(4%)and dysphagia(2%).Clinicians managed pain (69%),neurologic symptoms(51%),fatigue (49%),intestinal(21%),respiratory (19%) symptoms,bleeding (14%),insomnia (13%),nausea/vomiting(12%)and dysphagia(6%).Patients presented at all stages 79% at the time of their diagnosis of metastatic cancer,63% with an established ( > 1 month) metastatic cancer diagnosis and continuing to further cancer therapies and 17% proceeding to hospice care without further anti-cancer therapy after PRT. Conclusions: Radiation oncologists care for patients across time course of metastatic cancer diagnosis managing variety of urgent oncologic issues,most commonly metastases causing pain followed by brain metastases and cord compression.They also manage cancer-related symptoms,mostly pain,neurological symptoms and fatigue.These findings point to need for palliative care to be well integrated into radiation oncology practice including education and systems of care.
and higher palliative case volume (OR 2.59, 95%CI 1.45-4.63, pZ0.001). Stereotactic body radiation therapy (SBRT) was recommended overall in 16.4% of cases, and on multivariable analysis, significant predictors for SBRT recommendation were employment by an academic institution (OR 2.99, 95%CI 1.39-6.44, pZ0.005), decreased time since residency completion (OR 4.37, 95%CI 1.26-15.17, pZ0.02), spine location (OR 12.54, 95%CI 3.96-39.68, p <0.001), and prior radiation (OR 26.67, 95% CI 7.86-90.57, p <0.001). SF recommendation rates were overall higher compared to a similar 2009 survey (16.1% vs 9.4%, pZ0.0004). Conclusion: The recommendation of SF remains low, but appears to have increased since 2009, despite the presumed increased utilization of SBRT. We identify multiple key drivers in physician decision-making affecting SF recommendation that have not been addressed by prior level one evidence. We identify contemporary rates of recommendation of SBRT for treatment of bone metastases, and identify key drivers of SBRT recommendation. Further research with evidenced-based recommendations to clarify the role of SF and SBRT are needed, and may significantly impact practice.
24 Background: Patient-provider communication may impact patient satisfaction and engagement in decision-making. We aimed to understand patient preferences on radiation therapy (RT) discussions and to identify how to better communicate RT information. Methods: We conducted semi-structured interviews with 17 patients receiving palliative RT for lung or bone metastases at a single institution from 9/2016 to 10/2018. Patients’ answers about RT decision-making and communication were transcribed verbatim and analyzed qualitatively. We reviewed patients’ medical records to obtain demographic and clinical data. Results: The median age of patients was 64 years (range: 21-82). Most patients had metastatic cancer at diagnosis (53%) and had received prior palliative chemotherapy (71%) or RT (88%). The most common palliative RT course was 30 Gy in 10 fractions. Themes that impacted patients’ decisions to proceed with RT included trust in physicians (41%), desire to minimize pain or improve quality of life (35%), and a perceived lack of alternatives (35%). Most patients (76%) described the RT decision-making process as straightforward or logical. All patients reported receiving information from a physician on reasons to consider RT, while only 53% recalled discussions on reasons not to consider RT. Nearly all patients (88%) preferred shared patient-provider decision-making regarding cancer treatment; two patients (12%) preferred to be the main decision-maker. When discussing technical aspects of RT, 65% of patients reported that providers shared information on intensity of RT and number of treatments. Although 82% of patients reported that the provider was the sole decision-maker for the intensity of RT or number of treatments, all patients were satisfied and would not have wanted to be more involved in this decision. Conclusions: Trust in physicians, desire to minimize pain, and perceived lack of alternatives impact patients’ decisions to proceed with RT. Patients were more likely to remember physicians discussing reasons for RT as opposed to reasons not to consider RT. Most patients prefer shared decision-making regarding cancer treatment initiation but prefer physicians to make the decisions regarding RT treatment intensity.
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