When Does Early Palliative Care Influence Aggressive Care At The End of Life?

Abstract Background Early palliative care improves patient quality of life and influences cancer care. The time frame of early has not been established. Eight quality measures reflect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018 through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL). Methods Patients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30 days, 60–90 days, and greater than 90 days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with confidence intervals (CI) was reported as a measure of effect size. A p-value </= 0.05 was considered significant. Results 1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). 71% had a palliative care consult, 26% completed AD, 888 (51.4%) had at least one indicator of ACEOL. AD completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64–0.99). Palliative care was associated with a greater risk of ACEOL at 30 days (OR 5.32, 95% CI 3.94–7.18) and between 30 and 90 days (OR 1.39,95% CI 1.07–1.80), but dramatically reduced ACEOL at > 90 days (OR 0.46,95% CI 0.38–0.57).The most common indicator of ACEOL was new chemotherapy within 30 days of death, in 571 of 888 (64%) of patients experiencing ACEOL. Discussion AD reduce ACEOL and often reflect goals of care and end-of-life discussions in the transition of care away from tumor directed therapy. Palliative care paradoxically in our experience is associated with greater ACEOL in the first 90 days since consultation occurs late in the course of illness and the focus is on crisis management in patients who are frequently utilizing the health care system. If palliative care consultation occurs greater than 90 days before death, there is the opportunity for both aggressive symptom management and end of life discussions which may influence aggressive care at the end of life. Conclusions An initial palliative care consult greater than 90 days before death and ADs completed at any time during the disease trajectory significantly impacts care at the end of life. Both should become quality metrics for good cancer care.