Aggressive end-of-life care still common among older patients with cancer
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Key takeaways:
- Nursing home residents had a higher rate of aggressive end-of-life care than community-dwelling residents.
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Interventions to reduce its use should target hospital admission in the last 6 months of life and other factors linked to its use.
Aggressive end-of-life care remains common among older individuals with metastatic cancer despite increased efforts over the past several decades to reduce such interventions, according to study results published in JAMA Network Open.
Moreover, nursing home residents had a higher rate of aggressive end-of-life (EOL) care than their community-dwelling counterparts, researchers wrote.
“We were very surprised to see these findings,” Siran M. Koroukian, PhD, professor in the department of population and quantitative health sciences at Case Western Reserve University School of Medicine, told Healio. “Despite intensive efforts in the past decades to curb aggressive EOL care, and despite the wide recognition that such care is associated with little or no benefit, aggressive EOL care remained very common, and even more common among nursing home residents than in community-dwelling adults.”
Background, methodology
Nearly 150,000 persons residing in nursing homes have been or will be diagnosed with a form of cancer, according to study background. However, little is known about aggressive EOL care among this population, researchers wrote.
Koroukian and colleagues used the SEER database linked to the Medicare database and Minimum Data Set to identify deaths between 2013 and 2017 among 146,329 patients with cancer aged 66 years or older (mean age, 78.2 years; 51.9% men), with a lookback period in claims through July 1, 2012.
Cancer types included metastatic breast, colorectal, lung, pancreatic and prostate cancer.
Researchers identified several markers of aggressive EOL care, including cancer-directed treatment, ICU admission, having more than one ED visit or more than one hospitalization in the last 30 days of life, hospice enrolment in the last 3 days of life or in-hospital death.
Results
Researchers found aggressive EOL care to be more common among nursing home residents (63.6%) than community-dwelling residents (58.3%).
Results showed an association of nursing home status with 4% higher odds of receiving aggressive EOL care (adjusted OR [aOR] = 1.04; 95% CI, 1.02-1.07), 6% higher odds of having made more than one hospital admission in the last 30 days of life (aOR = 1.06; 95% CI, 1.02-1.1) and 61% higher odds of dying in the hospital (aOR = 1.61; 95% CI, 1.57-1.65).
In contrast, nursing home status appeared associated with a lower likelihood of receiving cancer-directed treatment (aOR = 0.57; 95% CI, 0.55-0.58), ICU admission (aOR = 0.82; 95% CI, 0.79-0.84) or enrollment in hospice in the last 3 days of life (aOR = 0.89; 95% CI, 0.86-0.92).
Study limitations included an inability to describe the circumstances that surrounded aggressive EOL care and whether it aligned with the patient’s preferences.
Next steps
Hospital admissions in the last 6 months of life, in-hospital mortality and other factors associated with aggressive EOL care should be targeted in interventions to decrease its use, according to researchers.
“We hope that our findings will raise health care providers’ and nursing home administrators’ awareness of the current ‘state of affairs’ in older adults with metastatic cancer, especially as it concerns in-hospital death among nursing home residents,” Koroukian told Healio. “It is important to conduct mixed methods research to gain a thorough understanding of the circumstances under which patients with terminal illness — especially those in nursing homes — receive aggressive EOL care.
“In particular, we need to better understand nursing homes’ decisions to transfer the patient to a hospital,” she added.
For more information:
Siran M. Koroukian, PhD, can be reached at skoroukian@case.edu.
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Koroukian SM, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.0394.
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