Care Quality and Cost Implications of the Timing of Palliative Care Consultation Among Patients with Advanced Cancer Treated at the UCSF Helen Diller Comprehensive Cancer Center (SA516-A)

Abstract

Review proposed procedures for pacemaker deactivation as developed by a tertiary university-based hospital. In the last several years, much has been written about the practical and ethical considerations regarding the deactivation of cardiac implantable electronic devices (CIEDs) in patients at the end of life. While deactivation of certain devices, such as implantable cardiac defibrillators, has become relatively common, other devices carry significantly more controversy and potential for conflict between patients and providers, as well as among medical professionals. Indeed, recent surveys have revealed that the majority of physicians remain uncomfortable discussing deactivate of CIEDs in general and pacemakers in particular. We will begin this concurrent session with a case report of a family's distress when their request for pacemaker deactivation in a patient with terminal cancer was met with accusations of euthanasia, and then review the literature regarding consensus and opinions regarding pacemaker deactivation. We will detail the experiences of one university-based hospital's attempt to develop a policy for pacemaker deactivation with an emphasis on practical lessons learned. We will review the results of a national survey of hospital-based ethics committees regarding their experience with pacemaker deactivation. Finally, we will end with a proposed procedure to manage the potential symptoms associated with pacemaker deactivation in a patient at the end of life. ObjectivesUnderstand the role of early palliative care in the treatment of patients with advanced cancer at the end of life. Recognize that specialty palliative care services are underutilized in patients with advanced cancer. Original Research Background. The American Society of Clinical Oncology (ASCO) recommends that palliative care (PC) be offered alongside standard oncologic care for patients with metastatic cancer and/or high symptom burden. There are limited data about how the timing of palliative care affects the quality, intensity, and cost of medical care at the end of life for patients with advanced cancer. Research Objectives. To understand how timing of PC referral is associated with the quality and cost of medical care delivered to patients with advanced cancer at the end of life. Methods. In this retrospective cohort study, we analyzed administrative and billing data to assess patterns of healthcare utilization of patients cared for at the UCSF Cancer Center who died from cancer between Jan 1, 2010, and May 31, 2012. Results. Among 978 decedents who received regular cancer treatment at UCSF, only 298 (30%) had specialty palliative care referrals. Of these, 94 (31.5%) had early PC referrals (EPC) while 204 (68.5%) had late PC (LPC). Patients who received EPC had a lower rate of inpatient admissions (33% vs 66%, p¼0.002), lower rates of ICU stay (5% vs 20%, p¼0.0005), and fewer ED visits in last month of life (34% vs 54%, p¼0.0002), as well as fewer instances of hospice service <3 days (7% vs 20%, p¼0.0001) and a lower rate of inpati...