LOS ANGELES – A palliative care consultation within the last month of life improves a variety of end-of-life outcomes in patients dying from gynecologic cancers, based on a retrospective analysis.
Among the 100 patients studied, about one-fourth had a timely palliative care consultation, defined in one study as 14 days before death and in another study as 30 days before death, lead investigator Dr. Nicole S. Nevadunsky of Montefiore Medical Center, New York, reported at the annual meeting of the Society of Gynecologic Oncology.
Dr. Nicole S. Nevadunsky
Compared with their counterparts who had late or no consultations, patients who had timely consultations had lower scores for aggressive end-of-life events such as emergency department visits, chemotherapy, and death in an acute care setting.
In addition, in their last 14 days of life, this group had median direct inpatient hospital costs that were $5,106 less, and they were half as likely to be admitted.
"Our data suggest that early palliative medicine consultation results in decreased aggressive measures at the end of life [and] was associated with decreased direct inpatient costs for women who died from gynecologic malignancies," Dr. Nevadunsky noted. "Further research is needed to evaluate the quality of life in relation to [the aggressiveness of care] for patients and their families."
While it is unclear how many gynecologic oncologists are also board certified in palliative care, "I think more clinicians actually do palliative medicine as part of their everyday practice," Dr. Nevadunsky said. Also, palliative care is truly a multidisciplinary undertaking involving, for example, nurses, pastoral care personnel, social workers, and others.
"As far as the best metric for palliative medicine, I think it is quality of life. But how to define that is extremely complicated and still evolving," she added.
"I think it’s an experience where the patient is getting what they want most out of things, and sometimes that’s saying to the patient, ‘If we can’t cure you, what is the most important thing to you?’ " she replied. "Each patient is different, and that’s what makes (defining quality of life) so complicated."
The American Society of Clinical Oncology recommends consideration of palliative care early in the course of metastatic or symptomatic disease.
"This is a very vague recommendation: who, what, when, where, how? How will patients respond to this? Who’s going to pay for this? What’s the patient going to get out of this?" Dr. Nevadunsky commented.
She and her colleagues studied 100 consecutive patients who died from gynecologic cancer between 2006 and 2009 and received care at Montefiore in the year before death.
In the first study, they defined a timely palliative care consultation as one occurring more than 30 days before death.
"The ideal timing for palliative medicine consultation is unknown; however, 30 days was chosen as the minimal exposure time because the standard metrics utilized to compare aggressive measures at the end of life included a minimum of 30 days," Dr. Nevadunsky explained.
"Overall, I was surprised to find that 49 of the 100 women actually had a palliative medicine consultation at some time or another during their care," she said.
However, the median number of days between consultation and death was 16, and only 18% of patients had a timely consultation.
Late diagnosis did not explain this finding, as less than 10% of patients received their diagnosis in the month before they died.
"The scope of this study was not inclusive to determine why this [late palliative care consultation] was happening," Dr. Nevadunsky said. Data showed that although the two groups were demographically similar, the patients who received a timely consultation were more likely to be married.
The group with timely consultations were less likely to receive aggressive end-of-life care, based on measures of eight indicators of aggressive care (0 vs. 2, P = .025).
The difference between those patients who had timely consultation and those with untimely or no consultation was greatest for the indicators of a hospital stay lasting more than 14 days in the last month of life (22% vs. 40%) and death in the acute care setting (28% vs. 45%).
In the second study, the investigators found that 29% of patients had a timely palliative care consultation, defined in this case as one occurring 14 days or more before death.
Patients with a timely consultation had lower median direct hospital inpatient costs per day in the last 30 days of life ($613 vs. $702, P = .02). They also had lower median direct hospital inpatient costs in the last 14 days overall ($0 vs. $5,106, P = .007) and on a per-day basis ($0 vs. $676, P = .007).