Context:
Many older adults discharged from an inpatient stay require postacute facility placement, which can be a barrier to hospice enrollment since the Medicare hospice benefit does not cover ...facility costs for patients under routine hospice care.
Objectives:
To evaluate the extent to which need for postdischarge facility care was a barrier to hospice enrollment for older patients with short life expectancy discharged from a palliative care unit.
Methods:
Retrospective cohort using a prospectively collected database of patients 65 and older with a life expectancy of <6 months admitted to a palliative care unit in an urban, academic medical center and discharged alive from 2012 to 2017. Primary outcome was hospice enrollment at hospital discharge. Exposure of interest was need for facility placement at discharge.
Results:
Of 817 included patients, 649 (79%) were discharged with hospice. Patients discharged home had a significantly higher rate of hospice enrollment than patients discharged to a facility—92% versus 71% (P < .0001). On multivariate logistic regression analysis, discharge to home versus facility remained a strong predictor of hospice enrollment, with an odds ratio for hospice enrollment of 6.04 (95% confidence interval: 3.73-9.79).
Conclusion:
Need for postdischarge facility placement represents a barrier for hospice enrollment among older patients who are otherwise hospice appropriate. The structure of the hospice benefit may require modification so that these hospice appropriate patients can utilize the benefit.
Despite advances in stroke care, patients continue to incur significant disability, are at risk for future events, and are inconsistently comanaged with palliative care (PC) specialty teams. The ...purpose of this study was to review patients with stroke admitted to our institution, comparing patients with and without PC consultation. We retrospectively reviewed medical record data of all patients with stroke admitted to our neurosciences ICU (NICU) in July 2014 to June 2015 with and without PC consultation. Review focused on stroke type, patient demographics, median days to discharge and death, and posthospitalization discharge. Of 463 patients admitted to the NICU with a stroke diagnosis, 27% (125/463) had (PC) consultation. A higher percentage of the patients with PC consult presented with hemorrhagic stroke than those without PC consult (38% vs 21%, P < .001). Patients with PC consult had longer median days to discharge and death (P < .001) and a higher percentage of mortality (32% vs 11%). Of the 301 patients without PC consult who discharged (89.1%), 36.5% discharged to inpatient rehab while 10% discharged to a skilled nursing facility. In comparison, of the patients with PC consultation who discharged alive (41.1%), 15.7% discharged to inpatient rehab whereas 39% discharged to skilled nursing (P < .001). The uncertainty of which patients with stroke benefit most from specialty PC is highlighted in that although sicker patients are referred to PC, a substantial portion (41%) of these patients discharge alive, of which 39.2% discharged to skilled nursing. Future research should focus on which patients with stroke would benefit from specialty PC.
BackgroundPalliative care (PC) is integral in the care of patients with advanced medical illnesses. The significant morbidity and mortality associated with therapeutic hypothermia (TH) after cardiac ...arrest calls for improved end-of-life care. The goal of this descriptive study was to review our institutional experience with PC consultation in this critically ill population.MethodsWe conducted a retrospective study of 319 consecutive patients undergoing TH post-cardiac arrest at Vanderbilt University Medical Center from May 2007 to April 2014. We compared intensive care unit characteristics of patients who received PC consultation (n=125) to those who did not (n=194). We performed Wilcoxon rank sum analyses for time on mechanical ventilation and vasopressor support and Pearson chi-square analyses for inpatient mortality, placement of a Do Not Resuscitate (DNR) order and withdrawal of life support.ResultsThe number of TH patients and PC consultations in this population increased over time (Figure 1). In the overall cohort, the mean age was 57.3 years (+/- 15.3), and 61% of patients were male. The PC group was mechanically ventilated longer (mean 5.18 vs. 3.45 days, p<0.001) with a trend toward longer vasopressor support (47.2 vs. 40.8 hours, p=0.055) and higher inpatient mortality (68% vs. 49%, p=0.001). PC consultation was also associated with a higher frequency of DNR order placement during hospitalization (75% vs. 36%, p<0.001) and increased frequency of withdrawal of life support (64% vs. 42%, p<0.001).ConclusionsIn our TH population, PC consultation increased over time, corresponding to our institution’s expansion of staffing, opening of a PC unit and integration of this service into our published TH protocol. Future studies may delineate the appropriate patient selection for PC consultation to better facilitate goals of care and medical decision-making.
Background:
Palliative care units (PCUs) staffed by specialty-trained physicians and nurses have been established in a number of medical centers. The purpose of this study is to review the 5-year ...experience of a PCU at a large, urban academic referral center.
Methods:
We retrospectively reviewed a prospectively collected database of all admissions to the PCU at Vanderbilt University Medical Center in the first 5 years of its existence, from 2012 through 2017.
Results:
Over these 5 years, there were 3321 admissions to the PCU. No single underlying disease process accounted for the majority of the patients, but the largest single category of patients were those with malignancy, who accounted for 38% of admissions. Transfers from the intensive care unit accounted for 50% of admissions, with 43% of admissions from a hospital floor and 7% coming from the emergency department or a clinic. Median length of stay in the PCU was 3 days. In hospital deaths occurred for 50% of admitted patients, while 38% of patients were discharged from the PCU to hospice.
Conclusion:
These data show that a successful PCU is enabled by buy in from a wide variety of referring specialists and by a multidisciplinary palliative care team focused on care of the actively dying patient as well as pain and symptom management, advance care planning, and hospice referral since a large proportion of referred patients do not die in house.
Colorectal (CRC) and anal (AC) cancer, both lower gastrointestinal (GI) cancers vary in their presentation and treatment. Overall, the incidence of CRC has decreased. However, the incidence of CRCs ...in younger adults has increased over the last 5 years. The incidence of ACs has increased, too. Women are disproportionally impacted by AC which is frequently associated with human papilloma virus (HPV). Patients diagnosed with both cancers often experience multiple symptoms including pain, constipation, nausea, and vomiting. Psychosocial distress including embarrassment and shame often results from both the cancers itself as well as surgical procedures such as creation of ostomy. Palliative care (PC) is an emerging specialty that focuses on maximizing the quality of life (QOL) for patients through expert symptom assessment and management, psychosocial support, and improved communication around illness. The evidence to support earlier integration of PC has steadily increased over the last ten years. The literature shows that early involvement of PC for these populations can result in improved QOL, improved symptom control and decreased intensity of care at the end of life. This article will review the palliative needs of patients diagnosed with CRC and discuss how PC as a specialty is well poised to support these needs.
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