Earlier Palliative Cancer Care Cuts End-of-Life ED Visits
A recent retrospective study found that earlier outpatient palliative care referrals for patients with advanced cancer were associated with a small increase in overall emergency department (ED) visits but significantly fewer end-of-life ED visits and improved advance care planning.
METHODOLOGY:
ED visits near end of life are common among patients with advanced cancer and often indicate unmet needs. Although early outpatient palliative care can improve symptom management and care coordination as well as prevent unnecessary ED visits, it is crucial to distinguish patients who require ED visits from those better managed with planned care.
To understand how earlier palliative care referrals may impact end-of-life ED visits, researchers conducted a retrospective cohort study of 3560 patients with advanced cancer (median age, 68 years; 60.2% men) referred to outpatient palliative care at Seoul National University Hospital between 2018 and 2022.
Patients received consultation-based palliative care services from a team of physicians, nurses, and social workers — provided 5 days per week, with telephone support available on weekdays.
Researchers analyzed ED visits after outpatient palliative care referral, looking at the association between the timing of palliative care referral and end-of-life ED visits as well as the completion of advance care planning documentation in outpatient palliative care and ED settings. Researchers also analyzed end-of-life ED visits — defined as those occurring within 30 days before death — and factors associated with overall and end-of-life ED visits.
TAKEAWAY:
Overall, 25.8% of patients visited the ED, and 10.6% had an end-of-life ED visit. Earlier palliative care referral was associated with a 4% greater likelihood of an ED visit overall (odds ratio [OR], 1.04), possibly because these patients had longer follow-up, but a 16% reduced likelihood of an ED end-of-life visit (OR, 0.84).
Factors associated with overall ED visits were age younger than 65 years (OR, 1.25), residence area (OR, 2.92), and planned treatment (OR, 2.60); factors associated with end-of-life visits were residence area (OR, 3.29), hematologic malignancy (OR, 2.79), and planned cancer treatment at referral (OR, 2.60).
Among 2132 patients who completed advance care planning documentation after referral, 48.0% of ED visitors and 52.8% of nonvisitors completed it at outpatient palliative care clinics, while 20.0% of ED visitors completed it in the ED.
End-of-life ED visits were more severe and were associated with longer median stays (11.6 vs 8.5 hours), higher rates of hospital admission or transfer (59.7% vs 41.5%), and higher rates of respiratory infections (13.5% vs 4.9%) than other ED visits.
Regarding interventions, cardiopulmonary resuscitation was performed more frequently during end-of-life ED visits than overall ED visits (3.2% vs 1.2%), with mechanical ventilation and vasopressors used nearly twice as often during end-of-life ED visits.
IN PRACTICE:
A substantial proportion of patients with advanced cancer visited the ED, including during the final month of life. Earlier palliative care referrals were associated with fewer end-of-life ED visits, 'emphasizing the importance of timely integration of [palliative care] to reduce unnecessary interventions and ensure goal-concordant care,' the authors wrote. The researchers also noted that the findings underscore the need for structured advance care planning discussions across care settings to enhance the quality of end-of-life care.
SOURCE:
This study, led by Ye Sul Jeung, MD, Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea, was published online in JAMA Network Open.
LIMITATIONS:
The single-center design limited the generalizability of the findings to other settings. This study could not capture data from other EDs where patients may have sought care, potentially leading to incomplete information. Moreover, this study did not consider the complex decision-making processes leading to ED visits, and lacked data on symptom burden or home circumstances to assess the necessity of the visits.
DISCLOSURES:
This research was supported by a grant from the Patient-Centered Clinical Research Coordinating Center, funded by the Ministry of Health and Welfare, Republic of Korea. The authors disclosed having no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Medscape
19 hours ago
- Medscape
Alcohol and Pancreatic Cancer: New Evidence About Risk
Does drinking alcohol increase the risk for pancreatic cancer? Researchers have long suspected it does, but the evidence has remained inconsistent. Now, a global study of more than two million people is firming up the case that a link exists. The study, which pooled data from 30 prospective cohorts, found that daily alcohol intake was associated with a 'modest' increased risk for pancreatic cancer in both women and men, regardless of smoking status. However, the extent of the risk depended somewhat on how the researchers modeled alcohol intake. One model, which mapped continuous increases in alcohol consumption, suggested there is no safe dose of alcohol — any amount can increase the risk for pancreatic cancer, though only by 3% for every additional 10 g of alcohol per day or about two thirds of a standard drink. The other model, which compared risk by alcohol volume categories, found that the risk does not become significant until a certain alcohol threshold — about two to three drinks per day for men and one to two for women. Still, overall, 'our findings provide new evidence that pancreatic cancer may be another cancer type associated with alcohol consumption, a connection that has been underestimated until now,' the study's senior author Pietro Ferrari, PhD, head of the Nutrition and Metabolism Branch at International Agency for Research on Cancer, said in a statement. The co-author Jeanine Genkinger, PhD, MHS, had a stronger take on the findings. 'I think this shows that alcohol use is a robust risk factor for pancreatic cancer,' said Genkinger, associate professor, epidemiology, Columbia University Mailman School of Public Health, New York City, noting that even more moderate drinking levels— no more than one drink for women and two for men — might be enough to boost pancreatic cancer risk. How Much of a Risk? The latest data, published in PLoS Medicine, come at a time of increased attention to the alcohol-cancer link. Earlier this year, then-US Surgeon General Vivek Murthy, MD, issued an advisory calling for cancer warnings to be added to alcohol labels. Major cancer organizations have determined alcohol to be an established risk factor for seven cancer types : those of the oral cavity, larynx, pharynx, esophagus, liver, breast, and colon/rectum. Despite the strong suspicion that drinking alcohol also contributes to pancreatic cancer risk, this aggressive cancer has not yet made the official list. The major reason is that the evidence surrounding an alcohol-pancreatic cancer link has been deemed 'inconsistent,' 'suggestive,' and 'inconclusive' by expert panels. Studies have been hampered by difficulties separating alcohol use from smoking — a known risk factor for pancreatic cancer — as well as varying findings by alcohol type and geographic location. In addition, certain studies highlighting a link have indicated that any association between alcohol and pancreatic cancer is driven only by more extreme drinking habits — more than four drinks a day, and sometimes as high as nine drinks. The latest analysis, Genkinger said, helps clarify uncertainty surrounding the alcohol-pancreatic cancer link, which is especially important for 'a disease where we don't have that many modifiable risk factors.' The findings are based on cohorts spanning four continents, all part of the Pooling Project of Prospective Studies of Diet and Cancer. Just under 2.5 million cancer-free participants were recruited between 1980 and 2013 (median age, 57 years), of whom 70% were alcohol drinkers, 47% were never-smokers, and 64% were alcohol drinkers and never smokers. Most study participants were from North America (60%), followed by Europe or Australia (32%) and Asia (8%). Alcohol intake was modeled in two ways: continuously for every 10 g/d increase and by volume threshold, using 0.1 to < 5 g/d as the reference for nondrinkers. For context, in the US, the amount of alcohol in a standard drink is defined as 14 g of pure alcohol — equivalent to a 12-ounce can of regular beer, a 5-ounce glass of wine, or a 1.5-ounce shot glass of distilled spirits. Over a median of 16 years, the researchers observed 10,067 incidents of pancreatic cancers. In the continuous model, the risk for pancreatic cancer rose by 3% for every additional 10 g of alcohol consumed per day (hazard ratio [HR],1.03; 95% CI, 1.02-1.04). This association remained consistent and significant among women and men (HR, 1.03 for both), current smokers (HR, 1.03), former smokers (HR, 1.02), and never-smokers (HR, 1.03), and across cohorts from Australia, Europe, and North America (HR, 1.03 for all), though not Asia (HR, 1.00). The research team also found evidence that the type of alcohol mattered: Alcohol from beer and liquor/spirits was associated with a significantly increased risk for pancreatic cancer (HR, 1.02 and 1.04, respectively) but alcohol from wine was not (HR, 1.00). This finding is in line with some previous studies suggesting that wine may have a different relationship with cancer risk compared with other alcoholic beverages. But Genkinger pointed out, this finding could 'reflect the ways in which people tend to drink different types of alcohol.' Wine, she noted, is often part of a meal, and people who favor wine may be less likely to binge drink than those who typically choose other types of alcohol. This study, however, did not survey participants about specific drinking patterns, including binge-drinking. In the threshold model, however, the increased risk only became significant once alcohol intake reached a certain level. For women, drinking one to two standard drinks per day raised their risk for pancreatic cancer by 12% compared with little to no drinking. For men, the threshold was a little higher: Consuming two to four drinks a day was associated with a 15% increase in risk, whereas drinking more than that was tied to a 36% greater risk. Overall, this research contributes to the growing body of evidence that pancreatic cancer should be added to the official alcohol-cancer risk list, according to Alison Klein, PhD, MHS, professor of oncology, pathology, and epidemiology, at Johns Hopkins School of Medicine, Baltimore, who was not involved in the research. Having the Conversation The recent Surgeon General's advisory encouraged clinicians to inform their patients that drinking is a cancer risk factor — something unknown to most Americans, according to recent survey findings. 'I think this study is a good reminder to all of us to talk to our patients about their alcohol use,' said Edward Thomas Lewis III, MD, an addiction psychiatrist and clinical assistant professor at the Medical University of South Carolina, Charleston, South Carolina. Providers can take opportunities for those discussions during routine care, such as when prescribing a medication that can interact with alcohol or when a patient's health condition, such as high blood pressure or heart disease, can be exacerbated by drinking. 'I think these are opportunities to really remind people about moderation,' Lewis said, 'and to talk about some of the individual risk factors that may cause someone to make changes related to their drinking.' It's also possible that drinking might interact with certain genetic variants to modify pancreatic cancer risk — an avenue Klein and colleagues are exploring. What's challenging, Lewis said, is advising patients on what level of drinking is 'Okay,' given that even lower levels of alcohol consumption — around one to two drinks per day — may carry some risk. 'There is no zero-risk alcohol use,' Lewis said. But, he added, people do not necessarily have to abstain to see benefits, either. 'So it may be that a patient, at the end of the day, is able to reduce their alcohol consumption by two or three standard drinks over a given week. That still has a positive net effect,' he said. Another challenge is patients often don't know what a 'standard drink' looks like and can underestimate how much they drink. Showing patients visual examples — such as these— can be an eye-opener, Lewis said. Given the associations between drinking alcohol and many health outcomes, Genkinger said, it's important for clinicians to discuss alcohol use, just as they would discuss physical activity and healthy body weight. 'These are all lifestyle factors that have an impact on numerous disease outcomes, not only pancreatic cancer,' she said.
Yahoo
20 hours ago
- Yahoo
I'm terrified of rabies, my Gen Z daughter fears climate change. Why anxiety is generational
Last month, I was convinced I had rabies. I didn't have any symptoms, or I'd hardly be sitting here writing this, but I was getting occasional intrusive flashes of panic that I was incubating the dread, 100-per cent-fatal virus that can first show symptoms months after exposure. My partner and I had been on holiday in Vietnam a few weeks before. As we were leaving a guesthouse in Ninh Binh, a friendly pet puppy skittered up behind me and lightly nipped my leg through my trousers. Now, there is rabies in Vietnam – 82 people died of it in 2023 – and you don't only get it from street dogs; it lurks even in puppies who seem playful. I weighed the evidence. I hadn't been vaccinated against rabies; most tourists don't bother because the jabs are expensive, and there is a 'post exposure' option if you do interact with a rabid animal. But because the skin on my leg hadn't been broken, I decided I was almost certainly going to be okay, carried on with my holiday, and basically forgot about it. Then, a few weeks after our return, the news was full of the terrible story of Yvonne Ford, a 59-year-old woman from Barnsley, who had died from rabies after being scratched by a puppy while on holiday in Morocco in February. Only scratched! Ford had started experiencing symptoms just two weeks prior to her death on June 11. Upon reading this, I started to worry – albeit in a controlled way. Should I get the 'post infection' set of jabs which would save me from certain death if I had been exposed? Was it worth the not insignificant £500 this would cost? Or should I just live with the very tiny risk? To add to my squirming brain, around this time there was a hostile incident between India and Pakistan, which the media always helpfully refer to as 'nuclear powers.' This brought back my teenage fear of nuclear war, of dying slowly of radiation sickness, as fed by such terrifying 1980s fare as the films Threads and The Day After. It really was Apocalypse Bingo for a while there, earlier this summer. I talked to my daughter, Annabel, 22, about what she made of my paranoias, and we started to explore the subject more deeply. I shared my Generation X fears: nuclear war, Aids – back in the day, at least – and rabies. (Who could forget those scary public information campaigns and screaming, red La Rage posters on cross-channel ferries?) Annabel, who is firmly Generation Z, told me she was worried about her economic future, 'brain aneurysms and freak deaths – I think this definitely comes from reading too much health journalism,' but most of all, climate change. 'Fears about climate change do occasionally keep me up at night,' she said. 'The heatwaves have been making me worried about the coming decades. It is clearly already happening. I think due to modern life we all forget how reliant we are upon the environment. Although the anxiety maybe isn't productive, I do think we should all be more concerned about climate change.' Why anxiety sticks with us I asked Owen O'Kane, a psychotherapist and the author of the bestselling book Addicted to Anxiety, what he made of all this. To a certain extent, the 'flavour' of our fears is due to what was making headlines at a formative period in our lives, he believes. 'Fashions change and we go through phases, your experience as an early adult stays with you,' he says. 'News headlines certainly don't help. The people who write them go for the worst-case scenario, the most catastrophic outcome. If you are anxious by nature, your 'anxious self' will gravitate towards these headlines.' If you tend towards anxiety, these more dramatic incidents are likely to affect you compared with an individual who is more sanguine. 'Anxious people are responsible people and they care deeply about things,' says O'Kane. 'They have a healthy altruistic core.' The problem, however, is that there's a risk anxiety can affect your life in a negative way. 'Your anxiety is like a watch guard, looking for a potential threat, and you might suddenly fixate on this threat,' says O'Kane. 'For example, a teenager might see a photo of a field of fire, and start worrying about climate change after a period of not thinking about it.' At heart, says O'Kane, anxiety is all about how much a person can tolerate the uncertainty of everyday life. 'To be worried is useful and has a function, to some degree,' he says. 'But it becomes a problem if we become obsessive, or avoid going out, for example. Every person has to do a cost-benefit analysis – where the price is not leading your life, and you become 'addicted' to your anxiety.' These days, says O'Kane, many people are 'frightened of our own shadow. 'The presentation and triggers are different, but these existential fears are actually our psyche asking fundamental questions: 'Will I get ill?', 'Will I die?', 'Will anyone help me?' 'Will I cope?'' And for our children's generation, the triggers are everywhere. 'People who are now in midlife didn't have social media,' says O'Kane. 'There was less exposure to world events. Yes, we knew there were wars and starvation and plane crashes; we were not unaware of these. But young people have a more elevated awareness of what's going on globally. It's not surprising that there are heightened levels of anxiety in Generation Z.' How social media fuels modern fears Annabel agrees with this analysis. 'Most of my fears are because of the news and social media, which allow little nuggets of anxiety to interrupt your day,' she says. 'Your phone pops up and it's another thing to be worried about, because that's what we engage with.' O'Kane suggests that anxieties can fluctuate, both in a negative way – in that they become harmful phobias – but also in a positive way, in that you can learn to manage and overcome them. I certainly concur with this: my teens and 20s were a mass of health anxieties, usually involving dread neurological diseases, all without a logical explanation. As I grew up, I learnt to keep a lid on these worries and defuse them. So, how did I resolve my rabies scare? First of all, I looked up the statistics of how many people had died of rabies in the UK after a foreign trip: six people between 2000 and 2024. I spoke to my sister-in-law, a GP, who reiterated my chance of contracting the virus was infinitesimal. I then texted the guesthouse in Vietnam, who told me the puppy had been vaccinated against rabies and was healthy. (I have to assume they were telling the truth.) As I received this reply, I was looking at my phone while crossing a road and almost got hit by a car. When I related the above to O'Kane, I was thrilled to have passed his 'healthy response' test. 'The situation was that you were bitten by a dog and there was rabies in the area,' he says. 'It's not dissimilar to how people felt during Covid. I wouldn't describe this as an irrational fear, but a 'situational one'. 'The context of your worry was normal and your parameters went up, you identified the trigger,' he says. 'Someone less prone to worry than you would have made the decision this was low risk and not worried at all afterwards. But you did the healthy thing for you – looked at the broader evidence, weighed it up, and let it go. You were able to acknowledge you could tolerate the worry. Someone more prone to worry would have been googling furiously, or have gone for the vaccinations.' O'Kane is at pains to point out that not all anxieties should be dismissed. 'I'm not saying you should tolerate all uncertainty, and there are useful, functional worries,' he says. 'For example, if you've had unsafe sex with someone you know is HIV positive, you should take the sensible medical approach and seek treatment.' And in less critical situations, we can lower our exposure to worrying material. 'I've gone off social media, and I'm feeling a bit better about everything,' says Annabel. 'It was overwhelming though, because there's so much online encouragement to optimise and do better – very Gen Z.' Broaden your horizons with award-winning British journalism. Try The Telegraph free for 1 month with unlimited access to our award-winning website, exclusive app, money-saving offers and more. Solve the daily Crossword
Wall Street Journal
21 hours ago
- Wall Street Journal
Stocks to Watch Tuesday: UnitedHealth, P&G, Whirlpool, Stellantis
↗️ UnitedHealth (UNH): The under-pressure healthcare conglomerate will report its first quarterly results since pulling its financial guidance and replacing its chief executive in May. Shares, which have shed more than 40% this year, rose in premarket trading. 🔎 Procter & Gamble (PG): The consumer-goods company is also due to report earnings. P&G said Monday that operations chief Shailesh Jejurikar would replace Jon Moeller as CEO from next year. ↘️ Whirlpool (WHR): The appliance maker cut its annual profit guidance and lowered its quarterly dividend. It said competitors have flooded the market with Asia-made products to beat the expected increase in tariffs. Shares skidded in off-hours trading.
