Talking with Patients about Dying Reply

New England Journal of Medicine (Impact Factor: 54.42). 10/2012; 367(17):1651-2. DOI: 10.1056/NEJMe1211160
Source: PubMed
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    ABSTRACT: The national confidential enquiry into patient outcomes and death (NCEPOD) set important benchmarks in assessing the quality of care received by patients dying within 30days of systemic anticancer therapy (SACT). Monthly morbidity and mortality audits conducted to recommendations in the NCEPOD were commenced at the Christie NHS Foundation Trust in 2009, specifically to assess and improve patient outcomes. We evaluated the outcomes of patients who died within 30days of SACT over a 4year period 2009-2013. We collated audit findings to determine the number of treatment related deaths, clinical characteristics of patients, causes of death and quality of care received. We examined the benefit of the audit in decreasing 30day mortality during the 4years and considered factors that may be associated with an increased risk of SACT related death. A total of 31,183 patients were treated at the Christie from 2009 to 2013. Of these 4% died within 30days of SACT. Death was treatment related in 11%. The decision to treat with SACT was appropriate in 87% of but there was room for improvement in care in 24%. Mortality decreased over the 4years. Possible factors associated with 30day mortality post SACT included performance status ⩾2, presence of comorbidities, treatment type and treatment setting. We demonstrated that our audit process is feasible and robust. Further areas of research to determine predictive scores for patient treatment selection and improve outcomes were highlighted and are ongoing. Copyright © 2014 Elsevier Ltd. All rights reserved.
    European journal of cancer (Oxford, England: 1990) 12/2014; DOI:10.1016/j.ejca.2014.11.011 · 4.82 Impact Factor
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    ABSTRACT: Purpose This study evaluates outcomes and patterns of care among patients receiving radiation therapy (RT) for bone metastases at a high-volume academic institution. Methods and Materials Records of all patients whose final RT course was for bone metastases from April 2007 to July 2012 were identified from electronic medical records. Chart review yielded demographic and clinical data. Rates of complicated versus uncomplicated bone metastases were not analyzed. Results We identified 339 patients whose final RT course was for bone metastases. Of these, 52.2% were male; median age was 65 years old. The most common primary was non-small-cell lung cancer (29%). Most patients (83%) were prescribed ≤10 fractions; 8% received single-fraction RT. Most patients (52%) had a documented goals of care (GOC) discussion with their radiation oncologist; hospice referral rates were higher when patients had such discussions (66% with vs 50% without GOC discussion, P=.004). Median life expectancy after RT was 96 days. Median survival after RT was shorter based on inpatient as opposed to outpatient status at the time of consultation (35 vs 136 days, respectively, P<.001). Hospice referrals occurred for 56% of patients, with a median interval between completion of RT and hospice referral of 29 days and a median hospice stay of 22 days. Conclusions These data document excellent adherence to American Society for Radiation Oncolology Choosing Wisely recommendation to avoid routinely using >10 fractions of palliative RT for bone metastasis. Nonetheless, single-fraction RT remains relatively uncommon. Participating in GOC discussions with a radiation oncologist is associated with higher rates of hospice referral. Inpatient status at consultation is associated with short survival.
    International journal of radiation oncology, biology, physics 08/2014; 89(5):1100–1105. DOI:10.1016/j.ijrobp.2014.04.028 · 4.18 Impact Factor
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    ABSTRACT: Background: Substantial health care resources are used on aggressive end-of-life care, despite an increasing recognition that palliative care improves quality of life and reduces health care costs. We examined the incidence of palliative care encounters in inpatients with incurable head and neck cancer (HNCA) and associations with in-hospital mortality, length of hospitalization, and costs.Methods: Data from the Nationwide Inpatient Sample for 80,514 HNCA patients with distant metastatic disease in 2001-2010 was analyzed using cross-tabulations and multivariate regressions.Results: Palliative care encounters occurred in 4,029 cases (5%) and were significantly associated with age ≥80 years, female sex, self-pay payor status, and prior radiation. Palliative care was significantly associated with increased in-hospital mortality and reduced hospital-related costs.Conclusions: Inpatient palliative care consultation in terminal HNCA is associated with reduced hospital-related costs, but appears to be underutilized and restricted to the elderly, uninsured, and patients with an increased risk of mortality. Head Neck, 2014
    Head & Neck 10/2014; DOI:10.1002/hed.23895 · 3.01 Impact Factor