The creation of an inpatient PCU resulted in a statistically significant reduction in both MICU mortality rate and MICU LOS, as terminally ill patients were transitioned out of the MICU to the PCU for end-of-life care. Our data support the hypothesis that a dedicated inpatient PCU, capable of providing care to patients requiring mechanical ventilation or vasoactive agents, can protect terminally ill patients from an ICU death, while providing more appropriate care to dying patients and their loved ones.
Background Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month’s costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL. Method Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value </= .05 indicated statistical significance. Results Of 608 eligible patients; 261 had no indicator, 133 had 1 and 214 > 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90 days before death was associated with increased costs while consultations >90 days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000. Discussion ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90 days before death reduces chemotherapy in the last month of life and AD reduces health care costs. Conclusion Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90 days before death; ADs reduce cancer health care costs.
BackgroundEarly palliative care improves patient quality of life and in uences cancer care. The time frame of early has not been established. Eight quality measures re ect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018 through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL). MethodsPatients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30 days, 60-90 days, and greater than 90 days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with con dence intervals (CI) was reported as a measure of effect size. A p-value = 0.05 was considered signi cant. Results1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). 71% had a palliative care consult, 26% completed AD, 888 (51.4%) had at least one indicator of ACEOL. AD completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64-0.99). Palliative care was associated with a greater risk of ACEOL at 30 days (OR 5.32,) and between 30 and 90 days (OR 1.39,95% CI 1.07-1.80), but dramatically reduced ACEOL at > 90 days (OR 0.46,95% CI 0.38-0.57).The most common indicator of ACEOL was new chemotherapy within 30 days of death, in 571 of 888 (64%) of patients experiencing ACEOL. DiscussionAD reduce ACEOL and often re ect goals of care and end-of-life discussions in the transition of care away from tumor directed therapy. Palliative care paradoxically in our experience is associated with greater ACEOL in the rst 90 days since consultation occurs late in the course of illness and the focus is on crisis management in patients who are frequently utilizing the health care system. If palliative care consultation occurs greater than 90 days before death, there is the opportunity for both aggressive symptom management and end of life discussions which may in uence aggressive care at the end of life.
Background. Cancer patients with a history of alcoholism express a higher level of symptom distress and are at risk for chemical coping. Research objectives. The purpose of our study was to determine the frequency of undiagnosed alcoholism among palliative care patients with cancer and explore the relationship with alcoholism, tobacco abuse, and use of illegal drugs. Methods. We reviewed 665 consecutive charts and identified 598 patients who then completed the CAGE questionnaire. One hundred consecutive CAGE positive (CAGE+) and CAGE negative (CAGE-) patients were identified. Tobacco and illegal drug use, Edmonton Symptom Assessment Scale, and Morphine Equivalent Daily Dose were collected. Results. Frequency of CAGE+ in our palliative care population was 100/598 (17%). Only 13/ 100 (13%) patients were identified as alcoholics prior to palliative care consultation. CAGE+ patients were younger (58.6 versus 61.3 years, p ¼ 0.07) and predominantly male (68/100 versus 51/100, p ¼ 0.021). CAGE+ patients were more likely to have a history of tobacco use (86/100 versus 48/100, p < 0.001), be actively smoking (33/100 versus 9/100, p ¼ 0.02), and have a history of illegal recreational drug use (17/100 versus 1/100, p < 0.001). At baseline, pain, sleep, dyspnea, and well-being were worse in CAGE+ patients, while pain and dyspnea were worse in patients with a history of nicotine use. CAGE+ patients were more frequently on opioids at the time of palliative care consultation (47/100 versus 29/100, p ¼ 0.01). Conclusion. Our data suggests that alcoholism is highly prevalent and misdiagnosed in patients with advanced cancer. CAGE+ patients expressed more symptom distress and were more likely to have a history of or actively engage in smoking and illegal recreational drug use placing them at risk for chemical coping. Implications for research, policy, or practice. Before prescribe opioids, clinicians need to carefully screen for behaviors that place patients at risk for chemical coping.
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