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Letting go of the rope - Aggressive treatment, hospice care, and open access

Dana-Farber Cancer Institute, Boston, USA.
New England Journal of Medicine (Impact Factor: 54.42). 08/2007; 357(4):324-7. DOI: 10.1056/NEJMp078074
Source: PubMed
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    ABSTRACT: To determine whether the receipt of chemotherapy among terminally ill cancer patients months before death was associated with patients' subsequent intensive medical care and place of death. Secondary analysis of a prospective, multi-institution, longitudinal study of patients with advanced cancer. Eight outpatient oncology clinics in the United States. 386 adult patients with metastatic cancers refractory to at least one chemotherapy regimen, whom physicians identified as terminally ill at study enrollment and who subsequently died. Primary outcomes: intensive medical care (cardiopulmonary resuscitation, mechanical ventilation, or both) in the last week of life and patients' place of death (for example, intensive care unit). Secondary outcomes: survival, late hospice referrals (≤1 week before death), and dying in preferred place of death. 216 (56%) of 386 terminally ill cancer patients were receiving palliative chemotherapy at study enrollment, a median of 4.0 months before death. After propensity score weighted adjustment, use of chemotherapy at enrollment was associated with higher rates of cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% v 2%; adjusted risk difference 10.5%, 95% confidence interval 5.0% to 15.5%) and late hospice referrals (54% v 37%; 13.6%, 3.6% to 23.6%) but no difference in survival (hazard ratio 1.11, 95% confidence interval 0.90 to 1.38). Patients receiving palliative chemotherapy were more likely to die in an intensive care unit (11% v 2%; adjusted risk difference 6.1%, 1.1% to 11.1%) and less likely to die at home (47% v 66%; -10.8%, -1.0% to -20.6%), compared with those who were not. Patients receiving palliative chemotherapy were also less likely to die in their preferred place, compared with those who were not (65% v 80%; adjusted risk difference -9.4%, -0.8% to -18.1%). The use of chemotherapy in terminally ill cancer patients in the last months of life was associated with an increased risk of undergoing cardiopulmonary resuscitation, mechanical ventilation or both and of dying in an intensive care unit. Future research should determine the mechanisms by which palliative chemotherapy affects end of life outcomes and patients' attainment of their goals.
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    ABSTRACT: Context. Although much is known about solid tumor patients who utilize hospice, the hematologic malignancies hospice population is inadequately described. Objectives To compare the characteristics and outcomes of hospice patients with hematologic malignancies to those with solid tumors. Methods We extracted electronic patient data (2008-2012) from a large hospice network (CHOICE), and used bivariate analyses to describe between-group differences. Results In total, 48,147 patients with cancer were admitted during the study period; 3518 (7.3%) had a hematologic malignancy. These patients had significantly worse Palliative Performance Scale scores (32% vs. 24% were below 40; P<0.001) and shorter lengths of stay (median 11 days vs. 19; P<0.001). They were more likely to die within 24 hours of hospice enrollment (10.9% vs. 6.8%; odds ratio [OR] 1.66, 95% confidence interval [CI] 1.49, 1.86, P<0.001) or within seven days (36% vs. 25.1%; OR 1.68, 95% CI 1.56, 1.81, P<0.001), and were more likely to receive hospice services in an inpatient or nursing home setting (OR 1.34, 95% CI 1.16, 1.56, and OR 1.54, 95% CI 1.39, 1.72, both P<0.001). Among hematologic malignancy patients, those with leukemia had the shortest survival (hazard ratio 1.23, 95% CI 1.13, 1.34, P<0.001), and 40.3% used hospice for less than seven days (OR 1.31, 95% CI 1.11, 1.56, P=0.002). Conclusion Hospice patients with hematologic malignancies are more seriously ill at time of admission, with worse functional status and shorter length of stay than other cancer patients. Differences in outcomes suggest the need for targeted interventions to optimize hospice services for the hematologic malignancies population, especially those with leukemia.
    Journal of Pain and Symptom Management 08/2014; DOI:10.1016/j.jpainsymman.2014.07.003 · 2.74 Impact Factor

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