What Matters in Survival is the Patient Not Early Palliative Care.

9101 Background: Early outpatient palliative care (PC) is an emerging practice and its key components have not been defined. We conducted a qualitative analysis of data from a randomized controlled trial which demonstrated improved quality of life, mood and survival in outpatients who received early PC integrated with standard oncologic care versus standard oncologic care alone. Our objectives were to 1) identify the content and key components of early PC clinic visits, 2) explore timing of key components, and 3) compare the content of PC and oncology visit notes at the critical time points of clinical deterioration and radiographic disease progression. Methods: We chose a random selection of 20 patients with newly diagnosed metastatic NSCLC who received early PC who survived within 4 time frames: less than 3 months (n=5), 3 to 6 months (n=5), 6 to 12 months (n=5) and 12 to 24 months (n=5). We performed content analysis on PC and oncology electronic health record notes of these patients using NVivo 9 software. Results: Addressing symptoms and coping ability were the most prevalent components of the PC clinic visits. The content of initial visits focused on building relationships and rapport with patients and their families and illness understanding. Discussions about prognostic awareness occurred during earlier visits while goals of care and hospice discussions occurred in later visits. The frequency of addressing these components was similar regardless of patients’ length of life. Comparing PC and oncology visits around critical time points, both included discussions about current illness status and goals of care; however PC visits emphasized symptoms, coping, and implications of anti-cancer treatments, while oncology visits focused on medical discussions about treatment plans. Conclusions: Early PC clinic visits emphasize managing symptoms, strengthening coping, and cultivating illness understanding and prognostic awareness in a structured, responsive and time-sensitive model. Around critical clinical time points PC and oncology visits have distinct features that suggest a key role for PC involvement while enabling oncologists to focus on anti-cancer management.

ObjectivesTo investigate whether cancer decedents who received palliative care early (ie, >6 months before death) and not-early had different risk of using hospital care and supportive home care in the...

e24009 Background: Early utilization of specialist palliative care (SPC) in cancer patients may reduce healthcare resource use, aggressive interventions, and costs at end-of-life. We evaluated the impact of SPC on healthcare resource utilization and aggressive interventions at end-of-life in patients who have died from lung cancer. Methods: Descriptive and multivariable logistic regression analyses were conducted on lung cancer decedents in the Calgary Zone, Alberta Health Services from 2008 to 2015. The primary exposure was timing of SPC (Early: receipt of SPC > = 90 days before death; Late: < 90 days before death; No SPC). The primary outcome was end-of-life healthcare resource use (defined as any of: hospital death, > 1 emergency department visit, > 1 hospital admission, > 14 days of hospitalization, ≥1 intensive care unit admission, ≥1 new chemotherapy program (or any chemotherapy in the last 14 days of life) in the 30 days prior to death. Results: There were 3300 patients of which the majority (51.6%) of decedents were male. More female versus male lung cancer decedents (36.4% vs 28.7%) received early SPC. After adjusting for confounders, a strong association was found between early, late or no SPC and end-of-life healthcare resource use (ORno exposure 3.25 (95% CI 2.41-4.40) vs ORlate exposure 2.44 (95% CI 2.03-2.92) compared to those with early SPC; p < 0.001). Males had 1.53 the odds of aggressive care at end-of-life compared to females (p < 0.001). Stratified analysis by sex revealed a strong association between the absence of SPC utilization and end-of-life healthcare resource use. Young age ( < 50 at death) was a strong driver of aggressive care at end-of-life in females versus males [OR 5.44 vs 2.53]. Conclusions: Early specialist palliative care was significantly associated with less end-of-life healthcare resource use in both male and female lung cancer decedents, with less early specialist palliative care use in males. Keywords: palliative care, early palliative care, cancer, end-of-life, healthcare resource use, lung cancer.

Background: Early palliative care interventions enhance patient outcomes, including quality of life, mood, and coping, but it remains unclear whether certain subgroups of patients are more likely to benefit from early palliative care. We explored whether age and sex moderate the improved outcomes seen with early palliative care. Methods: We performed a secondary analysis of data from a randomized trial of 350 patients with advanced lung and non-colorectal gastrointestinal cancer. Patients received an early palliative care intervention integrated with oncology care or usual oncology care alone. We used linear regression to determine if age (older or younger than 65) and sex moderated the effects of the intervention on quality of life (Functional Assessment of Cancer Therapy–General (FACT-G)), depression symptoms (Patient Health Questionnaire 9 (PHQ-9)), and coping (Brief COPE) within lung and gastrointestinal subgroups. Results: At 24 weeks, younger patients with lung cancer receiving early palliative care reported increased use of active coping (B = 1.74; p = 0.02) and decreased use of avoidant coping (B = –0.97; p = 0.02), but the effects of early palliative care on these outcomes were not significant for older patients. Male patients with lung cancer assigned to early palliative care reported better quality of life (FACT-G: B = 9.31; p = 0.01) and lower depression scores (PHQ-9: B = –2.82; p = 0.02), but the effects of early palliative care on these outcomes were not significant for female patients. At 24 weeks, we found no age or sex moderation effects within the gastrointestinal cancer subgroup. Conclusion: Age and sex moderate the effects of early palliative care for patients with advanced lung cancer. Early palliative care may need to be tailored to individuals’ unique sociodemographic and clinical characteristics.

A consensus document on early palliative care was produced by a committed Working Group of the Italian Society of Medical Oncology and the Italian Society of Palliative Care to improve the early integration of palliative care in medical oncology and to stimulate and guide the choices of those who daily face the problems of advanced stage cancer patients. The simultaneous administration of antineoplastic treatments and early palliative care was shown to be beneficial in metastatic cancer pathway outcomes. Patients who could benefit from early palliative care are those with an advanced cancer at presentation, a compromised PS for cancer, and/or morbidities, and who are too frail to receive treatment. According to the Bruera practice models, in which the combination of cancer management with early palliative care can be offered, three groups of patients needing simultaneous care were identified and three different models of the delivery of palliative care were proposed. In patients with good prognosis and low need of simultaneous care, the solo practice model and the request for consultations were suggested, while in patients with poor prognosis disease with high need of simultaneous care and in conditions with high need of simultaneous care, regardless of cancer prognosis, the integrated care approach should be offered. Palliative care consultation services are seldom accessible in the majority of Italian hospitals; thus the application of various practice models depends on available resources, and a shared care model with the structures of palliative care operating in the area is often required.

Patients with metastatic non-small-cell lung cancer (nsclc) experience great pain and stress. Our study aimed to explore the effect of early palliative care on quality of life in patients with nsclc. A total of 150 patients were randomly divided into two groups: control group with conventional care and study group with early palliative care. The quality of life (qol) rating scale and self-rating scale of life quality (sslq) were used to analyze the patients' quality of life. The Hospital Anxiety and Depression Scale-D/A (hads-d/a) and Patient Health Questionnaire 9 (phq-9) were used to analyze the patients' mood. Pulmonary function indexes of peak expiratory flow (pef), functional residual capacity (frc), and trachea-esophageal fistula 25% (tef 25%) were analyzed using the lung function detector. The qol and sslq scales scores of patients receiving early palliative care were significantly higher than those in the control group (p < 0.05). Moreover, the questionnaire results of the hads-d/a and phq-9 were better in patients receiving palliative care than in the control group (p < 0.05 or p < 0.01). In addition, analytical results of pulmonary function showed that the levels of pef, frc, and tef 25% in patients assigned to early palliative care were remarkably higher than those in the control group (p < 0.01 or p < 0.001). These data demonstrate that early palliative care improves life quality, mood, and pulmonary function of nsclc patients, indicating that early palliative care could be used as a clinically meaningful and feasible care model for patients with metastatic nsclc.

Assessment of palliative care for advanced non-small-cell lung cancer in France: A prospective observational multicenter study (GFPC 0804 study)

199 Background: Early referral to specialist palliative care can improve, or maintain, symptom and quality of life outcomes that matter most to patients facing life-limiting illnesses. We tested a multifaceted oncologist-facing intervention (Palliative Care Early and Systematic) in the real-world setting of a busy outpatient cancer clinic for its ability to increase the proportion of patients who receive early specialist palliative care (defined as ≥ 90 days before death). Herein, we describe how each component of the multi-faceted intervention, intended to bridge cancer, primary, and palliative care, impacted early use of specialist palliative care among advanced colorectal cancer patients. Methods: Two intervention components were implemented in Calgary, Alberta, Canada’s tertiary cancer centre from January 2019 to June 2020: 1) Adult colorectal cancer patients were referred to a community-based Clinical Nurse Specialist if they failed, or could not receive, first-line chemotherapy, or had high symptom burden (indicated by an Edmonton Symptom Assessment System Revised score ≥ 7); 2) Medical oncologists sent templated ‘Shared Care’ letters to patients’ primary care providers to improve communication, collaboration and role clarity. Results: N = 209 eligible patients died during the intervention period, of whom 57% experienced early referral to specialist palliative care. The median days from referral to death was 130 (IQR: 53-359). Of the 209, 28 (13%) saw the Clinical Nurse Specialist and received Shared Care letters, and all (100%) had early specialist palliative care referral (median 240 days, IQR: 161-359). 21/209 (10%) saw the Clinical Nurse Specialist but had no Shared Care letter. Of these 21, 76% had early specialist palliative care referral (median 197 days, IQR: 96-251). 43/209 (21%) had a Shared Care letter but no interaction with the Clinical Nurse Specialist. Of these 43, 53% had early specialist palliative care referral (median 102 days, IQR: 53-257). 117/209 (56%) did not interact with the Clinical Nurse Specialist or have a Shared Care letter. Of these 117, 45% had early specialist palliative care referral (median 86 days, IQR: 40-204). Conclusions: The Clinical Nurse Specialist was associated with the greatest increase in early specialist palliative care referral; however, the Clinical Nurse Specialist and Shared Care letters combined were associated with even greater (100%) early specialist palliative care use.

98 Background: The benefits of providing early palliative care (EPC) are well researched. Few studies have explored the knowledge and skill used by nurses to help patients and families transition to and receive palliative care. In this study, we examine the roles and responsibilities of nurses in the provision of EPC and explore some of the barriers and facilitators they encounter as part of this complicated work. Methods: We drew on constructivist grounded theory to guide our methods and analysis. Nurses were recruited from several ambulatory care clinics in a comprehensive cancer center in Ontario, Canada. Nurses who participated in the study completed semi-structured interviews seeking to examine the roles, responsibilities, knowledge, and skills they utilized to provide EPC. Results: Ten nurse practitioners, six staff nurses, and four advanced practice nurses completed interviews for a total of 20 participants. Participants practiced in a variety of settings such as head and neck, breast, pancreatic, and hematology. The core category Brokering Palliative Care includes three subcategories: (1) Moving backwards and forward – stepping back to assess patients’ willingness to hear about EPC and then proceeding by selling the benefits of palliative to improving everyday function; (2) Addressing misconceptions and stigma – dealing with patients’ assumptions about palliative care as diminishing hope and accelerating the end of life; and (3) Advocating with the interprofessional team – bringing patient concerns forward to the team, managing interprofessional dynamics, and seeding the process of referral to EPC. Conclusions: Oncology nurses play a central role by brokering EPC for patients with serious cancers and their families. They draw on their proximity to patients, relational and communication capabilities, care coordination skills, and advocacy abilities. Brokering palliative care is conditional on nurses’ comfort level, experience, workload, and relationships with other healthcare professionals, especially oncologists. Moreover, the brokering work of nurses must be enacted within the boundaries of the nursing role and their relative position within the healthcare system.

Palliative care has emerged as care that specifically aims to address gaps inherent in disease-centered approaches in order to enhance care quality in serious illness, both for patients and families and for health care systems. Late palliative care for patients with serious illness mitigates benefits to patients, families, and health care systems. Efforts have been made by investigators to define the impact of earlier palliative care interventions on patient, family and health care systems outcomes. We conducted a systematic review of randomized trials of outpatient and home palliative care, two locations where earlier palliative care do occur, to examine the evidence for palliative care benefits. Various terms were used; the search was performed in PubMed. From this search randomized trials were selected from 62 references derive from this search which appeared to be primary studies. Hand searches were done on references. Fifteen randomized control trials of outpatient palliative care and 13 randomized control trials of palliative home care were collected and collated into tables. Seven systematic reviews obtained and outcomes summarized in a table. Advantages to palliative care include improvement in certain symptoms such as depression, improved patient quality of life, reduced aggressive care at the end of life, increased advanced directives, reduced hospital length of stay and hospitalizations, improved caregiver burden and better maintenance of caregiver quality of life and reduction in the medical cost of care as well as patient and family satisfaction. There are randomized trials which demonstrate that symptoms and quality of life are not improved, and resource utilization and costs are not different from "usual" care. Seven systematic reviews of randomized trials came to similar conclusions. Notable methodological issues account for differences in results. Definitions of "early" palliative care vastly differed. There were no descriptions of what was meant by "usual" care in the control arm. Study designs and procedures were frequently flawed. Populations were heterogeneous in many studies and imbalances between randomly-allocated occurred frequently. Direct patient care versus consultation only, played a role. The assumption that the same model of care was equally effective across different diseases was unsubstantiated. Attrition was on average 40% and blinding of individuals who assessed outcomes frequently not mentioned. Power calculations were infrequent. Intention to treat analysis was often not done. Current studies fell short of the goal of measuring all relevant factors to assessing costs-benefits, having largely ignored the cost to the patient and family and instead focused narrowly on patient medical costs. Multiple studies have demonstrated several benefits to early outpatient palliative care for patients with newly diagnosed metastatic cancer. However, better designed and executed studies are needed to determine the best time to intervene and the best model of care.

Early integration of palliative care into oncology care has shown positive effects on patient symptoms and quality of life. It may also reduce health care costs. However given the heterogeneity of settings and interventions and the lack of information on the minimally effective dose for influencing care utilisation and costs, it remains uncertain whether early palliative care reduces costs. We sought to determine whether an early palliative care intervention integrated in usual oncology care in a Swiss hospital setting reduced utilisation and costs of health care in the last month of life when compared with usual oncology care alone. We performed a cost-consequences analysis alongside a multicentre trial. We extracted costs from administrative health insurance data and health care utilisation from family caregiver surveys to compare two study arms: usual oncology care and usual oncology care plus the palliative care intervention. The intervention consisted of a single-structured, multiprofessional conversation with the patient aboutsymptoms,end-of-life decisions,network building andsupport for carers (SENS). The early palliative care intervention was performed within 16 weeks of the diagnosis of a tumour stage not amenable or responsive to curative treatment. We included 58 participants with advanced cancer in our economic evaluation study. Median overall health care costs in the last month of life were 7892 Swiss Francs (CHF) (interquartile range: CHF 5637-13,489) in the intervention arm and CHF 8492 [CHF 5411-12,012] in the control arm. The average total intervention treatment cost CHF 380 per patient. Integrating an early palliative care intervention into usual oncology care showed no significant difference in health care utilisation or overall health care costs between intervention and control arms (p = 0.98). Although early palliative care is often presented as a cost-reducing care service, we could not show a significant effect of the SENS intervention on health care utilisation and costs in the last month of life. However, it may be that the intervention was not intensive enough, the timeframe too short or the study population too small for measurable effects. Patients appreciated the intervention. Single-structured early palliative care interventions are easy to implement in clinical practice and present low treatment costs. Further research about the economic impact of early palliative care should focus on extracting large, detailed cost databases showing potential shifts in cost and cost-effectiveness. gov Identifier: NCT01983956.

92 Background: Early palliative care (PC) referral can enhance quality of life (QOL) in patients with metastatic cancer and even improve overall survival in non-small cell lung cancer. Despite compelling data showing benefits of early integration of PC, barriers to care exist. Our institution recently established an outpatient PC service. To improve utilization of this new service we identified clinicians’ attitudes and barriers to PC, and provided education on the PC referral process. The effects of this intervention on PC utilization were assessed. Methods: We conducted a retrospective chart review of outpatient Hematology/Oncology (HO) referrals to identify patients referred for newly diagnosed, solid tumor malignancies with no curative options. Hospice referrals were excluded. We then formally surveyed clinicians participating in multi-disciplinary tumor boards to identify PC referral practices and attitudes/barriers to PC referrals. Education on PC and instruction on PC referral process were provided during this period. Post-intervention review of PC referrals over 4 months was conducted. Results: Prior to our intervention, of the 53 new consultations reviewed meeting study criteria only three (5.7%) patients were referred to PC. Our survey revealed that 66% (31/47) of oncology providers did not know the institution had onsite PC available and only eight (17%) knew how to place a referral. After education was provided, a second cohort revealed 24.1% (7/29) of patients were appropriately referred for early outpatient PC representing an 18.4% absolute increase. Conclusions: We significantly increased early PC referrals for HO patients with advanced or metastatic disease. However, other efforts to improve institutional awareness and change the culture of care to ensure that majority of these patients are appropriately referred. Longitudinal evaluation will further ensure that timely adjustments are made and that effects are permanent.

Regional studies show that children with cancer receive medically intense end-of-life (EOL) care, but EOL care patterns, including palliative care utilization in Alabama, remain unknown. This was a retrospective study of 233 children (0-19 years) who received cancer-directed therapy at Children's of Alabama and died from 2010 through 2019. Rates and disparities in palliative care utilization and the association between palliative care and intense EOL care, death location, and hospice were examined. The median death age was 11 years; 62% were non-Hispanic White. Forty-one percent had a non-central nervous system (CNS) solid tumor. Fifty-eight percent received palliative care, and 36% received early palliative care (≥30 days before death). Children without relapsed/refractory disease were less likely to receive palliative care than those who had relapsed/refractory disease (adjusted odds ratio [aOR], 0.2; 95% confidence interval [CI], 0.1-0.7). Children with CNS tumors and hematologic malignancies were less likely to have early palliative care (aOR for CNS tumors, 0.4; 95% CI, 0.2-0.7; aOR for hematologic malignancies, 0.3; 95% CI, 0.2-0.7) than children with non-CNS solid tumors. Late palliative care (vs none) was associated with more medically intense care (aOR, 3.3; 95% CI, 1.4-7.8) and hospital death (aOR, 4.8; 95% CI, 1.9-11.6). Early palliative care (vs none) was associated with more hospice enrollment (aOR, 3.4; 95% CI, 1.5-7.6) but not medically intense care (aOR, 1.3; 95% CI, 0.6-2.9) or hospital death (aOR, 1.8; 95% CI, 0.8-3.7). Fifty-eight percent of children dying of cancer in Alabama receive palliative care, but EOL care varies with the receipt and timing (early vs late) of palliative care. Whether this variation reflects differences in child and family preferences or systemic factors (eg, hospice access) remains unknown.

Objective: To assess the therapeutic effect of the early interdisciplinary palliative care based on WARM model (whole, assessment, revaluation, management) on the quality of life, psychological state, pain and nutritional status in patients with non-small-cell lung cancer (NSCLC). Methods: A total of 60 patients from Chongqing University Cancer Hospital with newly diagnosed advanced NSCLC from Oct 15, 2019 to Jun 12, 2020 were enrolled. According to the method of random number table, the patients were divided into two groups: standard oncologic care group (SC, n=30) and early palliative care group (EPC, n=30). SC group only received standard oncological care, while EPC group received standard oncological care and additional comprehensive treatment from a MDT consisted of medical oncologists, palliative care nurses, dietitians and psychologists. The quality of life [functional assessment of cancer therapy-lung (FACT-L) scale], psychological state [hospital anxiety and depression scale (HADS) and patient health questionnaire-9 (PHQ-9)], nutritional status [patient-generated subjective global assessment (PG-SGA)], and cancer pain status [numerical rating scale (NRS)] were observed and compared between the two groups before and after the 6 months treatment, respectively. Results: A total of 45 patients completed 6 months treatment, including 24 males and 21 females, aged 38-82 (60.5±1.7), with 23 patients in the EPC group and 22 patients in the SC group. Patients assigned to EPC group had a better quality of life than those assigned to SC group [FACT-L scale: (122.3±1.6) vs (111.8±2.1), P<0.001]. Fewer patients had anxiety and depressive symptoms in the EPC group than those in the SC group [HADS anxiety subscale: (1.1±0.3) vs (2.9±0.4), P<0.001; HADS depression subscale: (0.7±0.3) vs (3.6±0.4), P<0.001]. The PHQ-9 results showed that 100.0% (23/23) patients were free of depression in the EPC group, while 45.5% (10/22) patients were free of depression in SC group (P<0.001). Furthermore, patients in the EPC group had a better nutritional status [moderate malnutrition: 60.9% (14/23); no malnutrition: 39.1% (9/23)] than those in the SC group [severe malnutrition: 40.9% (9/22); moderate malnutrition: 50.0% (11/22); no malnutrition: 9.1% (2/22)] (P<0.001). There was no significant difference in NRS score between EPC group and SC group (P=0.140). Conclusion: Early interdisciplinary palliative care based on WARM model can improve the quality of life, psychological state and nutritional status in NSCLC patients.

This article refers to 'Palliative care in heart failure guidelines: A comparison of the 2021 ESC and the 2022 AHA/ACC/HFSA guidelines on heart failure' by M. Blum et al., published in this issue on pages xxx. The aim of the authors of this review 1 is to compare the guidelines of the 2021 European Society of Cardiology (ESC) (2021) 2 and those of the American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) (2022) 3 on the role of palliative care for patients with heart failure (HF). Four key issues raise from both guidelines: (i) what palliative care is; (ii) how palliative care is done; (iii) who provides palliative care; and (iv) when is the best time to integrate palliative care in HF care. Palliative care aims to alleviate suffering and improve quality of life (QoL) for persons living with life-threatening illnesses, personalizing the cure and achieving a 'middle way' between too much and too little treatment. 4 This translates into a most person-centred treatment based on prognosis, symptom control, QoL, and personal will. Historically, palliative care was offered to terminally ill patients at the end of their life. The growing prevalence of people living with advanced chronic conditions has extended the application of palliative care to non-cancer patients, including those suffering from diseases such as HF, with expected poor outcomes and those who suffer from an advanced stage of a life-limiting disease and, thus, the term 'early palliative care' was coined. 1, 3, 5 Practically, palliative care consists in a multidisciplinary approach to alleviate physical, psychological, social, nancial, and spiritual distress, extended to caregivers and including bereavement support. 6 This involves, among others, disease specialists, doctors and nurses expert in palliative care, physiotherapists, social workers, psychologists, psychiatrists, dieticians, spiritual counselors, volunteers, occupational therapists. Indeed, palliative care has a long history of attention to the multidimensional suffering of the patient and his family through rigorous The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.