Discharge Care Pathway (On-Off-Uncertain)
In the univariate analysis low Karnofsky level (P<0.0005), primary tumor (breast, P=0.028), the presence of the caregiver (P=0.004), less awareness of disease (P=0.001), indications for admission (toxicity due to anticancer therapies, P=0.019, other symptoms, P=0.006, and end of life care P=0.002), anticancer treatment in the last 30 days (0.001), referral setting (home care, P=0.004), MDAS at T0 and MDAS at TD (0.001 and <0.0005, respectively), weakness at TD (P<0.0005), depression at TD (P<0.0005), drowsiness at TD (P=0.004), appetite at T0 and TD (P=0.030 and 0.009, respectively), poor well-being at TD (P=0.003), global ESAS at TD (P=0.016), hospital staying (P=0.012), and discharge settings (home care, P<0.0005), were associated with the decision to definitely stop oncological treatments at discharge (off therapy). Age, sex, education, stage of disease, CAGE-positivity, smoking habits, the kind of admission (planned or not, readmission), amount of opioid rugs (OME), did not influence the discharge therapeutic pathway.
The multivariate regression analysis regarding the treatment pathway (on-off-uncertain) is showed in Table 3. Being “on-therapy” was independently associated with a lack of caregiver, home discharge, and shorter hospital admission, in comparison with off-treatment. In comparison with “uncertain” group, “on-treatment” was independently associated less admission for other symptoms, shorter hospital admission, discharge at home, and better well-being.
In the univariate analysis younger age (P=0.009), higher Karnofsky level (P<0.0005), stage of disease (no metastatic disease, P=0.038), patient awareness (P<0.0005), admission for uncontrolled pain (P=0.011), referral setting (home, P<0.0005), lower MDAS at T0 and TD (P=0.007 and 0.001, respectively), on-treatment (P<0.0005), no transfer from other units, P=0.012), higher pain intensity at T0 (P<0.0005), lower values of weakness (P<0.0005), nausea (P=0.004), depression (P<0.0005), anxiety (P=0.002), drowsiness (P<0.0005), dyspnea (P=0.030), insomnia (P=0.004), appetite (P=0.001), poor well-being (P<0.0005), and global ESAS at TD (P<0.0005) were associated with home discharge. The multivariate regression analysis is showed in Table 4 (discharge at home vs. home care, hospice or other). The only parameter independently associated with discharge home was “on-therapy.”
APSCU serves a very heterogenous population with different characteristics, in terms of stage of disease ongoing treatments, and reasons for admission, covering a broad range of cancer patients, just from time of diagnosis until the end of life. Thus, many patients are still receiving and possibly will continue anticancer therapies, have a short hospital staying, and are unlikely to die in hospital. Differently from what it was reported in hospitals in United States where half of them provide palliative care services,15 in most European countries, particularly Italy, most hospitals do not offer such opportunities, as palliative care is available as home care and hospice care services only, mainly not linked with the oncological setting, and accepting patients with a short survival in the last weeks of life.16 Instead, an early palliative care intervention may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone, and may increase use of approach-oriented coping, which was associated with higher quality of life and reduced depressive symptoms.17
This study provided a series of data influencing decision-making process at discharge from an APSCU, regarding either the oncological treatment and the care setting. In comparison to patients considered off-therapy, patients considered to benefit from continuing anticancer treatment (on) were more likely to do not have a caregiver, according to the definition adopted in this study, to be discharged home without specialized home care, and to have a shorter hospitalization. When compared with the gray area of patients defined “uncertain,” in which a definitive decision was not taken and postponed, patients “on-treatment” were more likely to have a shorter admission, to be discharged home, to have less admission for other symptoms, and a better poor well-being at discharge. Of interest, many other parameters taken into consideration in this study, including age, sex, education, stage of disease, CAGE-positivity, smoking habits, the kind of admission (planned or not, readmission), amount of opioid rugs (OME), did not influence the discharge disposition. The various variables examined did non influence the setting discharge, as the only variable associated with home discharge (without specialized home care service), was “on-therapy.” Conversely, off-therapy patients were more likely to be discharged to palliative home care or hospice care services. This finding is consistent with an appropriate selection of patients after being discharged by an APSCU, that works as a bridge between active treatment and supportive/palliative care, according the concept of early and simultaneous care. The therapeutic and settings pathways support the need of specialized beds in an oncological department, where it is possible reevaluate patients and provide the right direction, other than controlling symptoms.
Available literature regarding discharge disposition after admission to an APSCU is poor. In Italy almost all inpatients palliative care units are represented by hospices, where survival is short (about 18 d) and almost all patients die. From these data, it appears that hospice admission is only one way for end of life treatments. Thus, patients admitted to hospice receive specialized palliative care only for 2 to 3 weeks before death, implying an inacceptable timing for patients with several problems presumed to be present early during the course of disease.2
In a pioneer study, 59 and 41 patients discharged from an acute palliative care were transferred home and to hospice, respectively. Younger patients, a better functional status, being married, and with a better cognitive status, evaluated with Mini-Mental State Examination, were more likely to be transferred home. However, data regarding the trajectory of oncological treatments was unavailable.18 In a more recent study, patients admitted to an inpatient palliative care unit, 45% of them were discharged, with a mean hospital staying of 15 days, and 55% died. Karnofsky status and palliative performance scale were higher for discharged patients.19 No correlation was found between the pattern of sociodemographic variables. Moreover, the inpatient mortality was quite different from that reported in an unit like that presented in this study and previous surveys (3% to 7% of patients).4,5 In a study performed with a large sample of advanced cancer patients admitted to an acute palliative care unit, 958 (33%) patients died during admission, while 592 (20%), 855 (29%), 404 (14%) 56 (2%), and 33 (1%) patients were sent home, home hospice, inpatient hospice, long-term care facilities, and other institutions, respectively. Home discharge was associated with a longer survival in comparison with hospice transfers. Younger age and direct admission to the acute palliative care unit were independently associated with home discharge.15 Data regarding the care pathway were not available, and other possible determinants of discharge, including symptom severity and Karnofsky status, were unavailable. Considering the different inpatient death rate (about 1/3), it is likely that many of these patients were severely ill in comparison with patients reported in this study. In a study including inpatients and patients seen for palliative care consultation, almost all patients were discharged to palliative care services. Stable care trajectories were found for patients with a short survival, a median of 24 days.20 In patients with unplanned admission to an oncological unit, discharge location was influenced by a substantial physical and psychological symptom burden. However, data refers to a general oncologic ward.21
Globally, from data of literature it seems that most palliative care units admit very advanced cancer patients with short survival and a relatively high mortality rate during admission. Thus, existing data are hard to compare with data of the present study. Despite calls for integrated palliative care, this frequently occurs late. The application of targeted cancer-specific transition points, for example an APSCU, to trigger integration of palliative care as a standard part of quality oncological care and to provide appropriate discharge disposition, are of paramount importance.18
For these reasons, patients admitted to our APSCU may not representative of patients with cancer, and results cannot be generalizable. However, this model, that seems to deliver the earliest palliative care, should be widespread as it allows a precious weapon in the context of the concept simultaneous care. APSCU admission is not only useful for symptom control , toxicities, end of life care, but also to allow an appropriate patients’ assessment according to more strict palliative care criteria and a multidisciplinary evaluation of the individual therapeutic options. In other words, APSCU may enhance coordination of care. providing a junction to choose the best pathway in terms of oncologic treatment and care setting. Another limitation is represented by the lack of information about survival. However, many patients lived at long distance from this regional center, and there was no way to gather this information.
It would be relevant to compare different models, for example external consultation or mobile teams of palliative care in oncological wards. For instance, it has been shown that APSCU allows a better planning admission to hospital and a better care trajectory in comparison to a busy oncological ward in a similar population of advanced cancer patients.22,23 Thus, specialized palliative care beds may facilitate the management of advanced cancer patients in the context of a busy oncological ward.
1. Bruera E, Hui D. Integrating supportive and palliative care
in the trajectory of cancer: establishing goals and models of care. J Clin Oncol. 2010;28:4013–4017.
2. Mercadante S, Vitrano V. Palliative care
in Italy: problems areas emerging from the literature. Minerva Anestesiol. 2010;76:1060–1071.
3. Cheng WW, Willey J, Palmer JL, et al. Interval between palliative care
referral and death among patients treated at a comprehensive cancer center. J Palliat Med. 2005;8:1025–1032.
4. Mercadante S, Adile C, Caruselli A, et al. The palliative-supportive care
unit in a comprehensive cancer center as crossroad for patients’ oncological pathway. PLoS One. 2016;11:e0157300.
5. Mercadante S, Villari P, Ferrera P. A model of acute symptom control unit: Pain Relief and Palliative Care
Unit of La Maddalena Cancer Center. Support Care Cancer. 2003;11:114–119.
6. Rigby A, Krzyanowska M, Le LW, et al. Impact of opening an acute palliative care
unit on administrative outcomes for a general oncology ward. J Clin Oncol. 2008;113:3267–3274.
7. Smith T, Coyne P, Cassel B, et al. A high volume specialist palliative care
unit and team may reduce in-hospital end-of life care costs. J Palliat Med. 2003;6:699–705.
8. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care
for patients with advanced cancer
: a cluster-randomised controlled trial. Lancet. 2014;383:1721–1730.
9. Bruera E, Kuehn N, Miller MJ, et al. The Edmonton Symptom Assessment Scale (ESAS): a simple method for the assessment of palliative care
patients. J Palliat Care. 1991;7:6–7.
10. Chang VT, Hwang SS, Feurman M. Validation of the Edmonton Symptom Assessment Scale. Cancer. 2000;88:2164–2171.
11. Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007;1:33–41.
12. Parsons HA, Delgado-Guay MO, El Osta B, et al. Alcoholism screening in patients with advanced cancer
: impact on symptom burden and opioid use. J Palliat Med. 2008;11:964–968.
13. Lawlor PG, Nekolaichuk C, Gagnon B, et al. Clinical utility, factor analysis, and further validation of the memorial delirium assessment scale in patients with advanced cancer
: assessing delirium in advanced cancer
. Cancer. 2000;88:2859–2867.
14. de la Cruz M, Ransing V, Yennu S, et al. The frequency, characteristics, and outcomes among cancer patients with delirium admitted to an acute palliative care
unit. Oncologist. 2015;20:1425–1431.
15. Hui D, Elsayem A, Palla S, et al. Discharge outcomes and survival of patients with advanced cancer
admitted to an acute palliative care
unit at a comprehensive cancer center. J Palliat Med. 2010;12:49–57.
16. Mercadante S, Valle A, Sabba S, et al. Pattern and characteristics of advanced cancer
patients admitted to hospices in Italy. Support Care Cancer. 2013;21:935–939.
17. Haun MW, Estel S, Rücker G, et al. Early palliative care
for adults with advanced cancer
. Cochrane Database Syst Rev. 2017;6:CD011129. Doi:10.1002/14651858.CD011129.pub2.
18. Fainsinger RL, Demoissac D, Cole J, et al. Home versus hospice inpatient care: discharge characteristics of palliative care
patients in an acute care hospital. J Palliat Care. 2000;16:29–34.
19. Masel EK, Huber P, Schur S, et al. Coming and going: predicting the discharge of cancer patients admitted to a palliative care
unit: easier than thought? Support Care Cancer. 2015;23:2335–2339.
20. Kotzsch F, Stiel S, Heckel M, et al. Care trajectories and survival after discharge from specialized inpatients palliative care
; results from an observational fllow-up study. Support Care Cancer. 2015;23:627–634.
21. Lage DE, Nipp RD, D’ Arpino SM, et al. Predictors of posthospital transitions of care in patients with advanced cancer
. J Clin Oncol. 2018;36:76–82.
22. Mercadante S, Marchetti P, Adile C, et al. Characteristics and care pathways of advanced cancer
patients in a palliative-supportive care
unit and an oncological ward. Support Care Cancer. 2018;26:1961–1966.
23. Collins A, Sundararajan V, Burchell J, et al. Transition points for the routine integration of palliative care
in patients with advanced cancer
. J Pain Symptom Manage. 2018;56:185–194.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
advanced cancer; palliative care; supportive care; discharge disposition