People with cancer who sought palliative care early were less likely to receive aggressive care in their final month and die in a hospital bed compared with those who received palliative care later. These results appeared in BMJ Open.
“Across an 11-year population-based, cancer cohort, those who received early palliative care (before six months of death) compared with a matched cohort of those who did not, were more likely to receive supportive home care and less likely to receive hospital care in the last month of life,” wrote the researchers.
Accessing palliative care early may improve quality of life while reducing acute care requirements. However, some patients are not offered palliative care until they are expected to die within six months, and insurance rules may require that they forgo potentially curative treatment. Starting palliative care early and in tandem with cancer treatment is recommended, but its impact on reducing acute care needs towards the end of life is unclear.
Hsien Seow, PhD, of McMaster University in Ontario, Canada, and colleagues conducted a study to ascertain if people with cancer who received early palliative care at least six months prior to death versus those who did so later had different risks for hospital and supportive home care during the last month of their lives.
For this study, the team looked at people with cancer who died between 2004 and 2014 in Ontario. Using administrative information and medical billing, they matched individuals who had received early and later palliative care.
The team split the population into two groups—those that received home care assessments using the Resident Assessment Instrument (RAI), called the Yes-RAI group, and those that did not, deemed the No-RAI group. The RAI is used to collect specific details about an individual’s strengths and requirements, which are then used to create a personalized care plan. Including this measure helped the researchers control for confounding variables linked to receiving palliative care earlier, such as worsening pain, depression, cognitive decline and more.
The main outcomes were hospital death in an acute care setting, supportive home care and aggressive care within the last month of life. The team considered aggressive care as admission to the hospital or intensive care unit (ICU) and at least one trip to the emergency room. A physician house call for palliative care, end-of-life care in the form of home nursing or personal support at home was defined as supportive home care.
For the No-RAI group, the team included 36,238 pairs that received earlier and later palliative care. In terms of aggressive care, people from the No-RAI group who received palliative care earlier had lower risk compared with those who received palliative care later. Some 38% of the early group died in a hospital compared with 48% of the late group, an absolute risk difference of 10%. Those who received early palliative care also had a 10% lower likelihood of aggressive care. Further, they had a 10% lower likelihood of visiting the emergency department, a 10% lower chance of hospital admission and a 4% lower likelihood of ICU admission during the last month compared with those who received such care later.
The results for the 3,586 pairs from the Yes-RAI group were similar, with lower risks for those in the early palliative care group.
For the No-RAI group, those who received care early were more likely to need supportive home care compared with those who received palliative care later. Early recipients of palliative care had an 23% higher aggregate measure of supportive home care compared with late recipients. Around 56% of early palliative care recipients had home care nursing within the final month of life compared with 34% of late recipients, an absolute risk difference of 22%. Early recipients also had a 10% higher likelihood of a house call from a physician and a 16% higher likelihood of care from an end-of-life personal support worker in the final month compared with later recipients.
For the Yes-RAI group, while the results trended similarly, the absolute risk difference of receiving any of these supportive home care services was 38% higher among early adopters of palliative care.
Overall, early recipients of palliative care had a 10% to 13% lower risk of dying in a hospital and a 10% lower risk of aggressive care in the final month as well as a 23% to 38% higher likelihood of needing end-of-life supportive home care.
“Our findings suggest that policies and education strategies to support the delivery of early palliative care might reduce the risk of dying in hospital and receiving aggressive care at end of life in real-world settings,” wrote the study authors. “In particular, policies that prohibit the access of palliative care services unless one forgoes curative treatments or is certified as expected to die within six months or less are disincentives to earlier and concurrent access to palliative care.”
Click here to read the study in BMJ Open.