The Magnitude and Effects of Early Integration of Palliative Care Into Oncology Service Among Adult Advanced Cancer Patients at a Tertiary Care Hospital

Abstract

Background

Palliative care (PC) has a positive effect on symptom burden, quality of life, psychosocial communication, prognostic understanding, mood, and quality of care at the end of life of patients with advanced cancer.

Objectives

To investigate the timing of the first palliative consultation and referral of advanced cancer patients to the palliative care service and their determinants at King Faisal Specialist Hospital and Research Center (KFSHRC), Jeddah, Saudi Arabia.

Subjects and methods

A retrospective cohort study was conducted at KFSHRC. It included advanced cancer patients who died between January 1, 2019 and Jun 30, 2020. The dependent variable of primary interest is the timing of PC consultation and the timing of PC referral. The independent variables included age, sex, marital status, nationality, date of death, types of cancer, Eastern Cooperative Oncology Group (ECOG), palliative performance status (PPS), palliative prognostic index (PPI), code status (do not resuscitate [DNR]), the severity of symptoms (assessed by the Edmonton Symptom Assessment System - Revised [ESAS-r]), referral to home health care (HHC), referral to long-term care (LTC), referral to interdisciplinary team (IDT), length of survival after the first PC consultation, length of survival after the referral to the PC service, length of hospital stay, frequency of emergency room (ER) visits and hospital admission in the last year before death, and involvement in bereavement with advanced care planning (ACP) services.

Results

Of the 210 advanced cancer patients, 109 (51.9%) were male, and their ages ranged between 18 and 90 years. More than half of patients (56.7%) had a history of PC consultation. Among them, PC consultation was described as late in 60.5% of patients. Concerning the timing of palliative care referral among advanced cancer patients, it was too late and much too late among 25.7% and 58.1% of them, respectively. Patients who visited ER more frequently (≥3 times) (p=0.014) and those who referred to HHC (p=0.005) were more likely to consult PC early compared to their counterparts. Length of survival was significantly higher among patients who reported early PC consultation compared to those without PC consultation and those with late PC consultation, p<0.001. Referral to PC for both transfer of care and symptom management was associated with earlier PC consultation, p=0.021. Patients who were admitted to the hospital three times or more were less likely to be much too late referred to PC services, p=0.046. Also, patients who were not referred to long-term care or home health care were more likely to be referred to PC services much too late, p<0.001. Among 28.8% of patients whose PPS ranged between 30% and 50% compared to 14.9% of those whose PPS ranged between 10% and 20% expressed too late referral time to PC, p=0.040.

Conclusion

In a considerable proportion of terminal cancer patients, palliative care was consulted late, and the timing of palliative care referral was too late/much too late among most of those consulted palliative care. Length of survival was higher among patients who reported early PC consultation and who with ideal referral time to PC services than others. Therefore, future considerations to facilitate early integration of palliative care in cancer patients are highly recommended through mainly improving staff education in communication skills and palliative care approach.