Assessing the utilization of the decision to implement a palliative goal for the treatment of cancer patients during the last year of life at Helsinki University Hospital: a historic cohort study

Abstract

Background: To avoid aggressive treatments at the end-of-life and to provide palliative care (PC), physicians need to terminate futile anti-cancer treatments and define the palliative goal of the treatment in time. This single center study assesses the practices used to make the decision that leads to treatment with a palliative goal, i.e., the PC decision and its effect on anti-cancer treatments at the end of life. Material and methods: Patients with a cancer diagnosis treated in tertiary hospital during 1st January 2013-31st December 2014 and deceased by the end of 2014 were identified in the hospital database (N ¼ 2737). Of these patients, 992 were randomly selected for this study. The PC decision was screened from patient records, i.e., termination of cancer-specific treatments and a focus on symptom-centered PC. Results: The PC decision was defined in 82% of the patients during the last year of life (49% >30 days and 33% 30 days before death, 18% with no decision). The median time from the decision to death was 46 days. Systemic cancer therapy was given during the last month of life in 1%, 36% and 38% (p < .001) and radiotherapy 22%, 40% and 31% (p ¼ .03) cases, respectively; referral to a PC unit was made in 62%, 22% and 11%, respectively (p < .001). In logistic regression analyses younger age, shorter duration of the disease trajectory and type of cancer (e.g., breast cancer) were associated with a lack or late timing of the PC decision. Conclusion: The decision to initiate a palliative goal for the treatment was frequently made for cancer patients but occurred late for every third patient. Younger age and certain cancer types were associated with late PC decisions, thus leading to anti-cancer treatments continuing until close to the death with low access to a PC unit.

The impact of the duration of the palliative care period on cancer patients with regard to the use of hospital services and the place of death: a retrospective cohort study

“…We have earlier demonstrated with this same cohort of patients [19] that a PC decision initiating the palliative goal for care was frequently made, but occurred late [11]: the median time from the PC decision to death was 46 days. Patients with no or a very late PC decision (<30 days) received more aggressive cancer treatments at the EOL and made fewer visits to the PC unit.…”

“…In our earlier study [19], we reported that PC decisions done within the last month prior to death were associated with anti-cancer treatments continuing until close to death, and the access to a PC unit becoming more unlikely. Therefore, a well-timed decision to initiate a palliative period might also be related to more appropriate treatment and resource usage at the EOL.…”

“…The data and data sources used in the study are the same as in [19], but some new variables were considered in addition to those in [19]: do not resuscitate (DNR) decisions, visits to the ED in secondary/tertiary hospitals, inpatient episodes in secondary/tertiary hospitals, appointments to PC units, timing of the PC decision, and the date and place of death. Most data used in this study was available in a structured format and exported directly from the electronic medical records.…”

“…The cancer diagnoses were grouped in the same way as in [19] into 13 groups. When the patient had more than one malignancy, the cancer diagnosis was recorded to match the primary cause of death.…”

“…The PC decision and the PC period are defined as in [19]. For the purposes of this study patients were divided into three separate categories: 'no PC decision', 'PC decision', and 'PC decision and appointment to a PC unit'.…”