Outpatient palliative care may have distinct benefits for patients with cancer
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Palliative care appeared associated with increased hospice utilization and advanced care planning among patients admitted to an inpatient oncology unit, according to study results published in JCO Oncology Practice.
Additionally, patients who received outpatient palliative care had shorter hospital length of stay and longer hospice length of stay, researchers noted.
Rationale
“Palliative care is a specialized type of medical care that focuses on improving quality of life for all patients and families facing a serious illness,” Jonathan C. Yeh, MD, researcher at Beth Israel Deaconess Medical Center and Harvard Medical School, told Healio. “It is delivered by specially trained physicians, nurses and nurse practitioners, as well as other supportive staff such as social workers, interfaith chaplains and pharmacists. However, many individuals have not heard of palliative care or may believe that it is the same as end-of-life care — but this is not true.”
Several research trials during the past 15 years have shown that early, integrated palliative care delivered alongside curative care helps people live better and longer, Yeh said.
“However, many of these wonderful early palliative care trials focused on palliative care in the outpatient clinic setting,” he continued. “Despite all of these research studies, palliative care clinics and home-based programs remain severely underfunded in the United States. Even though most cancer centers now have a palliative care team, they tend to see more hospitalized patients rather than clinic outpatients.”
Methodology
Yeh and colleagues gathered data on 522 patients with cancer admitted to an inpatient oncology unit between Oct. 1, 2017, and Sept. 30, 2018.
“We specifically looked at decedents [patients who died] because we wanted to understand more about the quality of their end-of-life care,” Yeh said. “We wanted to ask how many patients saw inpatient vs. outpatient palliative care, and how did the quality of their care compare.”
Key findings
Half of the decedents received palliative care, of whom 21% had an outpatient palliative care visit.
Compared with those who never received palliative care, those who received palliative care in any setting fared better, with a higher likelihood of enrollment in hospice (78% vs. 44%; P < .001), having do-not-resuscitate status (87% vs. 55%; P < .001), having advanced care planning documents (53% vs. 31%; P < .001), and dying at home or in inpatient hospice care (67% vs. 40%; P < .01).
“We believe this was because the palliative care team helped patients and their families identify what matters most when people are getting sicker by providing expert communication that combines honesty with empathy,” Yeh said. “As a result, people made different end-of-life choices than they would have made if they never had the support of the palliative care team.”
Moreover, patients who received outpatient palliative care experienced longer hospice length of stay (46.5 days vs. 27.1 days; P < .01) and less end-of-life intensive care (6% vs. 15%; P < .05) than those who received inpatient palliative care.
“We believe this is because our clinic patients were even more prepared to make tough decisions,” Yeh said. “We had also known them for longer and built up a stronger relationship with them and their families. They were better prepared to have tough conversations, such as the right time to start hospice care and the type of support needed to help patients spend their last days at home instead of in the hospital.”
Implications
The findings add to those of many other studies within the past 10 to 20 years that show the benefits of palliative care, Yeh told Healio.
“We believe it is important for hospitals and health systems to increase funding and support for palliative care clinics and home-based programs, so that palliative care teams can reach people as soon as possible when they begin to deal with a serious illness,” Yeh said.
To ensure as many hospitalized patients with cancer as possible have access to palliative care, Yeh said Beth Israel Deaconess Medical Center started a new care model.
“Our palliative care team is working closely with leaders in the cancer center, and we are committed to providing maximum support for patients and families with cancer from the very first day of each hospital stay,” he said. “We hope this will allow us to reach more people and make cancer treatment easier, regardless of whether it is going well or poorly. We are continuing to collect detailed outcomes data from this project and hope to publish the results of this new care model in late 2022 or early 2023.”
Outpatient-integrated palliative care clearly improves outcomes for patients with cancer, and Yeh and colleagues add more evidence about these benefits, Neha Kayastha, MD, researcher in the department of medicine, and Thomas W. LeBlanc, MD, MA, MHS, researcher in the division of hematologic malignancies and cellular therapy, both at Duke University School of Medicine, wrote in an accompanying editorial.
“It is tragic that despite more than a decade of evidence and society guideline recommendations, we are still failing to provide what we know is a helpful service for patients and families. We must do better. We must educate ourselves, our colleagues and our patients; create more robust processes for needs-based referrals; support improved clinical infrastructure and advocate for legislation such as the Palliative Care and Hospice Education and Training Act,” they wrote.
References:
Kayastha N, et al. JCO Oncol Pract. 2021;doi:10.1200/OP.21.00794.
Yeh JC, et al. JCO Oncol Pract. 2021;doi:10.1200/OP.21.00546.
For more information:
Jonathan C. Yeh, MD, can be reached at Beth Israel Deaconess Medical Center, 330 Brookline Ave., Yamins 100 Suite, Boston, MA 02215; email: jyeh3@bidmc.harvard.edu.
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