Early Palliative Care May Curb Aggressive End-of-Life Care

Increasing the uptake of palliative care may decrease the aggressiveness of end-of-life care, an analysis of ovarian cancer decedents suggested.

Palliative care initiated earlier than 3 months before death was associated with lower rates of emergency department (ED) visits, hospital admissions, and intensive care unit (ICU) admissions in the last 3 months of life. It was also associated with a lower rate of death in the hospital.

“When patients with advanced or incurable cancers experience aggressive end-of-life care, spending their final weeks of life in and out of the ED or admitted to acute care hospital wards or the ICU, where they undergo invasive tests or procedures that may not meaningfully prolong life or address symptoms or suffering, this can be very distressing for patients and their caregivers,” lead author Sarah J. Mah, MD, of McMaster University in Hamilton, Ontario, Canada, told Medscape Medical News.

The researchers’ previous study showed that access to palliative care increased from 2006 to 2018 among patients with gynecologic cancers in Ontario. “However, even with over 95% of patients receiving some form of palliative care and 52% accessing a palliative care specialist, the rate of aggressive end-of-life care did not change over that same time period,” said Mah. 

That finding led the researchers to ask the questions at the center of the current study, which was published online on October 28 in JAMA Network Open. How much does the timing of palliative care initiation matter? How early is early enough to initiate palliative care for it to be associated with less aggressive end-of-life care? 

Implementation Strategies Needed

Researchers analyzed health data from ovarian cancer decedents across Ontario to identify palliative care provision from 2006 to 2018. The primary outcome was the associations between the timing of palliative care and end-of-life quality indicators, including ED use, hospital or ICU admission in the last 30 days of life, chemotherapy in the last 14 days of life, death in the hospital, and a composite measure of aggressive care. Late palliative care was defined as that initiated ≤ 3 months before death.

A total of 8297 ovarian cancer decedents were included in the analysis. Their mean age at death was 69.6 years, and their mean oncologic survival was 2.8 years. Among 3958 patients with known cancer stage, 3495 (88.3%) presented with stage III or IV disease. One third (2667) received late palliative care. 

Results of multivariable regression analysis showed that any palliative care started earlier than 3 months before death was associated with lower rates of aggressive end-of-life care (odds ratio [OR], 0.47), death in the hospital (OR, 0.54), and ICU admission (OR, 0.46). 

Furthermore, a consultation with a palliative specialist from 3 months up to 6 months before death was associated with a lower likelihood of late chemotherapy (OR, 0.46).

“We also found that even when we excluded palliative care provided by specialists, early primary palliative care was still associated with a lower likelihood of aggressive end-of-life care,” said Mah. “Given the shortage of palliative care specialists, this means that family physicians, oncologists, and other team members involved in the care of patients with cancer have an important role to play.” 

“Implementation strategies for early palliative care initiation are needed to optimize care quality and health resource utilization at the end of life,” the authors concluded.

“Developing our skills in patient-centered communication, symptom assessment and management, and identifying triggers for specialist referral is an important competency in contemporary practice,” Mah added.

The study has several limitations, including the use of retrospective data that do not capture private-payer services and may not capture all relevant end-of-life quality indicators. There were no cancer stage data available for more than half of the cohort.

The use of administrative data limited the analysis of the association of palliative care timing with patient-reported outcomes, as well as the concordance of end-of-life care with patient and caregiver preferences.

Many Misconceptions

May Hua, MD, associate professor of epidemiology at Columbia University Mailman School of Public Health in New York City, commented on the study for Medscape Medical News. “One interpretation is that early palliative care prevents healthcare use at the end of life. But it may be that people who received late palliative care did so because they were predisposed to using aggressive care (ie, patients were opting for aggressive care, and thus, were referred by their clinicians to palliative care).” Hua, who did not participate in the study, is an ICU attending physician and expert in palliative care. 

“Another caveat is that early palliative care is largely focused on improving quality of life, which is not measurable in population-level studies but has been consistently shown to be improved in randomized controlled trials,” she said.

“There are multiple reasons for patients to not have received specialist palliative care, despite guidelines from the American Society of Clinical Oncology recommending early integration,” she noted. “There is a national shortage of palliative care clinicians, there may be a hesitation on the part of the oncology clinician to refer (eg, they don’t want the patient to feel abandoned), and there also may be reluctance on the part of the patient due to a lack of education and misconceptions about what palliative care is.”

Like Hua, Mah pointed to “the many persistent misconceptions around the definition and intent of palliative care in our healthcare system and more broadly in society” as barriers to referral. “Commonly, [people think] that palliative care is the same thing as end-of-life care, that it is only used when patients are dying or have no treatment options left or that it leads to loss of hope for patients and caregivers and thus shouldn’t be introduced too early.” 

An important part of addressing these barriers, she said, “is in knowledge translation, and normalizing [the idea] that care that emphasizes symptom management, quality of life, and centering of patient autonomy and values has a place alongside conventional anticancer treatment. It is likely that people with other cancer types or serious or life-threatening illnesses similarly are receiving palliative care late, if at all, and may benefit from earlier initiation.” 

In a related editorial, Ada Hsieh, MD, MPH, a fellow in gynecologic oncology, and Lilian T. Glen, MD, a gynecologic oncologist, both at the University of Toronto, Toronto, Ontario, Canada, wrote that “limited resources and time constraints” are also barriers to palliative care. “This study by Mah et al highlights the importance of multidisciplinary palliative care in this patient population and considerations for implementation strategies with nonspecialist palliative care practitioners to help with resource management,” they concluded.

This study received funding from a Juravinski Hospital and Cancer Centre Foundation research grant (RD-223). It also was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. Mah reported receiving personal fees from GSK outside the submitted work. Hua, Hsieh, and Glen reported no relevant financial relationships. 

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.