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Addressing Disparities in End-of-Life Care in Blood Cancers

Laura Joszt
While use of palliative care at the end of life has increased, disparities remain, and not all patients who are terminally ill with blood cancers are having discussions about their goals of care at the end of life.
Discussions about goals of care can improve end-of-life care for patients, and 2 abstracts presented at the 60th American Society of Hematology Annual Meeting and Exposition analyzed when these discussions are taking place as well as disparities regarding these discussions.

The first study1 analyzed what impact timing and location of goals-of-care discussions had on the quality of end-of-life care. The researchers studied 384 patients who died of blood cancer between January 1, 2014, and December 31, 2014. Fewer than two-thirds (61.2%) had a documented goals-of-care discussion. One-third (33.2%) of the discussions that did occur happened more than 30 days before death.

The most common topics during goals-of-care discussions were resuscitation preferences (82.6%) and hospice (30.6%). However, the preferred location of death was only part of 3.4% of discussions.

The authors found that 21.6% of all patients studied had at least 1 intensive care unit (ICU) admission 30 days or fewer before death. However, not only did having a goals-of-care discussion have a significant impact, but when that discussion took place was important. Among those patients who had the first end-of-life discussion more than 30 days before their death, only 14.1% had an ICU admission 30 days or fewer before death compared with 40.8% of patients whose first discussion took place fewer than 30 days before death. If that first discussion took place in an outpatient setting, there was also a lower likelihood of ICU admission 30 days or fewer before death (9.4% vs 44%).

Having the first goals-of-care discussion in the outpatient setting was also significantly associated with higher rates of hospice use (41.2% vs 24.0%) and a lower likelihood of hospital death (25.9% vs 70.7%).

The second abstract2 presented analyzed trends in palliative care use and disparities in palliative care use at the end of life at the patient and hospital levels. The authors studied 7789 patients with multiple myeloma who died in the hospital and found only 32.5% received palliative care. While use of palliative care increased annually, disparities remained. In 2008, use of palliative care was only 17.3%, which increased to 43.0% in 2014. However, patients who were black (odds ratio [OR], 0.72; 95% CI, 0.62-0.82) or Hispanic (OR, 0.48; 95% CI, 0.38-0.60) had a lower likelihood of palliative care use.

The type of hospital and where it was geographically located made a difference as well. Palliative care was more likely in teaching hospitals versus nonteaching hospitals and in larger hospitals versus smaller hospitals, the researchers found.

“While some of the hospital-level disparities can be explained by the relative lack of palliative services in small non-teaching hospitals, barriers to accessing palliative care services needs to be thoroughly investigated and addressed to ensure equal access to this important aspect of care in terminally ill cancer patients,” the authors concluded.

References

1. Odejide OO, Cronin AM, Murilla A, Tulsky JA, Abel GA. Impact of timing and location of goals of care discussions for patients with blood cancers. Presented at: 60th American Society of Hematology Annual Meeting and Exposition; December 2, 2018; San Diego, California. Abstract 973.

2. Mohammed KA, Osazuwa-Peters N, Sanfilippo KM. Sociodemographic and hospital level disparities in palliative care utilization among terminally ill patients with multiple myeloma. Presented at: 60th American Society of Hematology Annual Meeting and Exposition; December 2, 2018; San Diego, California. Abstract 3594.

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