Winifred Teuteberg

Improvement in symptom burden within one day after palliative care consultation in a cohort of gynecologic oncology inpatients

OBJECTIVE The aim of this study is to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. METHODS Women with a gynecologic malignancy and PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographic and disease characteristics. Symptom scores on a modified Edmonton Symptom Assessment System (ESAS) scale were abstracted for pain, anorexia, fatigue, depression, anxiety, nausea and dyspnea. Prevalence of moderate-to-severe symptom intensity was compared between the day of PC consultation (D1), the day after PC consultation (D2) and the last recorded symptoms before discharge (DLast). RESULTS PC was consulted for symptom management during 129 admissions of 95 unique patients. Median age was 59, 84% were white and 67% had stage III/IV disease, with ovarian the most common site (52%). Symptom prevalence on D1 for at least mild intensity ranged 14% (dyspnea) to 80% (pain) and for at least moderate intensity from 3% (dyspnea) to 50% (pain). Statistically significant decreases in prevalence of moderate to severe symptom intensity between D1 and DLast occurred for pain, anorexia, fatigue and nausea (magnitude 58-66%) and between D1 and D2 for pain, fatigue and nausea (magnitude 50-55%). The majority of the improvement that occurred between D1 and DLast happened by D2. CONCLUSIONS PC consultation is associated with improvement in symptom burden, the majority of which occurs within one day of consultation. PC may be an effective tool for symptom management in patients with moderate to severe symptom intensity even during short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief.

Predictors of palliative care consultation on an inpatient gynecologic oncology service: Are we following ASCO recommendations?

OBJECTIVE Determine predictors of inpatient palliative care (PC) consultation and characterize PC referral patterns with respect to recommendations from the American Society of Clinical Oncology (ASCO). METHODS Women with a gynecologic malignancy admitted to the gynecologic oncology service 3/2012-8/2012 were identified. Demographic information, disease and treatment details and date of death were abstracted from medical records. Students t-test, Fischers exact test or χ(2)-test was used for univariate analysis. Binomial logistic regression was used for multivariate analysis. RESULTS Of 340 patients analyzed, 82 (24%) had PC consultation. Univariate predictors of PC consultation included race, cancer type and stage, recurrent disease, admission frequency, admission for symptom management or malignant bowel obstruction (MBO), discharge to skilled nursing facility (SNF) and number of lines of chemotherapy. On multivariate analysis, significant predictors of PC consultation were recurrent disease (OR 2.4, 95% CI 1.1-5.3), number of admissions (≥ 3, OR 10.9, 95% CI 3.4-34.9), admission for symptom management (OR 19.4, 95% CI 7.5-50.1), discharge to SNF (OR 5, 95% CI 1.9-13.5) and death within 6 months (OR 16.5, 95% CI 6.9-39.5). Of patients considered to meet ASCO guidelines, 53% (63/118) had PC referral. Of patients referred to PC, 51.2% (42/82) died within 6 months of last admission. CONCLUSIONS Patients referred to inpatient PC have high disease and symptom burden and poor prognosis. High-risk patients, including those meeting ASCO recommendations, are not captured comprehensively. We continue to use PC referrals primarily for patients near the end of life, rather than utilizing early integration as recommended by ASCO.

Primary palliative care for heart failure: what is it? How do we implement it?

Heart failure (HF) is a chronic and progressive illness, which affects a growing number of adults, and is associated with a high morbidity and mortality, as well as significant physical and psychological symptom burden on both patients with HF and their families. Palliative care is the multidisciplinary specialty focused on optimizing quality of life and reducing suffering for patients and families facing serious illness, regardless of prognosis. Palliative care can be delivered as (1) specialist palliative care in which a palliative care specialist with subspecialty palliative care training consults or co-manages patients to address palliative needs alongside clinicians who manage the underlying illness or (2) as primary palliative care in which the primary clinician (such as the internist, cardiologist, cardiology nurse, or HF specialist) caring for the patient with HF provides the essential palliative domains. In this paper, we describe the key domains of primary palliative care for patients with HF and offer some specific ways in which primary palliative care and specialist palliative care can be offered in this population. Although there is little research on HF primary palliative care, primary palliative care in HF offers a key opportunity to ensure that this population receives high-quality palliative care in spite of the growing numbers of patients with HF as well as the limited number of specialist palliative care providers.

Improvement in Symptom Burden Within One Day After Palliative Care Consultation in a Cohort of Gynecologic Oncology Inpatients (FR435-B)

Objectives List three symptoms that were statistically significantly improved within one day of PC consultation for symptom management in our cohort of gynecologic oncology inpatients. Synthesize the results of this study into one or two sentences that could be used to advocate for greater integration of specialty palliative care consultation into the care of gynecologic oncology inpatients. Original Research Background: The impact of inpatient palliative care (PC) on symptom burden in the gynecologic oncology (GO) population has not been evaluated. Research Objectives: Evaluate the magnitude and time course of change in symptom burden after PC consultation in a cohort of GO inpatients. Methods:

“Ask me, do you want to know the big picture?” Gynecologic oncology patient and provider perspectives on discussing prognosis.

37 Background: Prognosis affects decision making by providers and patients and accurate understanding of prognosis may help avoid futile end-of-life care. Gynecologic oncology (GO) patient and provider perspectives on discussing prognosis have not been described. We sought to analyze patient and provider preferences regarding timing, amount and type of information included in discussions of prognosis. METHODS Semi-structured qualitative interviews regarding palliative care with 19 GO providers (7 physicians, 7 advanced practice providers, 5 nurses) and 29 patients with advanced or recurrent gynecologic cancer at an academic medical center. Communication about prognosis was one interview domain. Two coders independently and iteratively analyzed transcripts using qualitative analysis. RESULTS Median patient age was 61, the most common cancer was ovary (59%) and 90% had recurrent disease. Providers were 74% female with median 15 years in practice. Themes included patients wanting frank discussions about prognosis, not limited to life expectancy. Further preferences regarding timing and content were individualized. All categories of providers reported having prognosis conversations. Providers saw these conversations as part of their clinical role, though they often found them difficult. Providers commonly equated prognosis purely with life expectancy. Providers recognized variation among patients in preferences regarding these conversations, but did not discuss asking patients directly about their preferences. CONCLUSIONS GO patients want frank discussions about what the future might hold, often including but not limited to life expectancy. Providers see these discussions as being within their scope of practice but often find them difficult. Opportunities exist for provider education regarding communication skills for assessing patient preferences and conducting patient centered prognosis discussions. Education should include GO physicians, advanced practice providers and nurses. Collaboration with specialty palliative care providers could facilitate that education and provide assistance with challenging cases.

Implementation of clinical triggers for palliative care consultation on a gynecologic oncology inpatient service: A pilot study.

51 Background: Our objectives were to (1) Assess the feasibility of creating clinical triggers for Palliative Care (PC) consultation on a large gynecologic oncology service and (2) Use triggers to increase PC consultation rates among trigger positive patients. METHODS Clinical triggers for PC consultation are listed below. Over a six month period, patients meeting triggers were prospectively identified and PC consultation was requested for those patients. Retrospective chart review was used to identify patients meeting triggers and gather clinical information. PC consultation rates were compared for patients meeting triggers in the 6 months pre and post trigger implementation. Statistical analysis utilized χ2 test, Fishers exact test and independent samples t-tests. RESULTS There was no difference in PC consultation rates among patients meeting triggers between the pre and post-triggers periods (see table). There was also no change in time from admission to PC consult (median time to PC consultation 1.56d vs. 2.24d, p=0.28) and no change in overall PC consultation volume (mean 17.3 new PC consults per 100 admissions/month vs. 18.5, p=0.67). Of the 38 patients in the post-triggers period who were not seen by PC, 50% (n=19) were inaccurately deemed trigger negative during their admission and 13% (n=5) were not screened at all. CONCLUSIONS Creation of clinical triggers for PC consultation was feasible in terms of investment from relevant stakeholders. Trigger implementation was not associated with increased rates of PC consultation for those patients. High baseline rates of PC consultation and screening process issues contributed significantly to the lack of change in PC consultation rates. Use of clinical triggers may still hold promise as a strategy for standardizing PC consultation patterns and capturing subgroups of patients with high needs. Next steps include modifying our clinical triggers and screening process and expanding into the outpatient setting. [Table: see text].

Change in symptom burden within one day of palliative care consultation in a cohort of gynecologic oncology inpatients.

28 Background: Change in symptom burden after inpatient palliative care consultation for symptom management in gynecologic oncology patients has not been described. Our objective was to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. METHODS Women with a gynecologic malignancy and a PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographics and disease characteristics. PC provider reports of patient symptom intensity on a modified Edmonton Symptom Assessment System were retrospectively reviewed. Data was analyzed with descriptive statistics and two sample test of proportions to compare prevalence of moderate to severe symptom intensity on the day of consultation to the day after consultation. RESULTS Over 12 months, there were 172 PC consultations for symptom management involving 123 unique patients. The median age was 58 and most common cancer was ovarian (44%), followed by cervical (26%) and uterine (24%). Prevalence of moderate to severe symptoms on the day of consultation is outlined below. There were statistically significant decreases in prevalence of moderate to severe symptom intensity within one day of PC consultation for pain, anorexia, fatigue and shortness of breath (SOB) (see table). CONCLUSIONS PC consultation is associated with significant improvements in symptoms within one day of consultation. Palliative care consultation may be an effective tool for symptom management during even very short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief. [Table: see text].