Supportive Care in Cancer

, Volume 20, Issue 9, pp 2189–2194

The quality of supportive care among inpatients dying with advanced cancer

  • Anne M. Walling
  • Steven M. Asch
  • Karl A. Lorenz
  • Jennifer Malin
  • Carol P. Roth
  • Tod Barry
  • Neil S. Wenger
Short Communication
  • 456 Downloads

Abstract

Purpose

Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center.

Methods

Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ≥3 days at one university medical center between April 2005 and April 2006.

Results

Of 496 decedents, 118 had advanced cancer (mean age 60, 54 % male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56 % of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23 % had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80 %, range 50–100 %). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26 % of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29 % of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69 % of cases, respectively.

Conclusions

This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.

Keywords

Quality of care Supportive care Advanced cancer 

References

  1. 1.
    Steinhauser KE et al (2000) Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 284:2476–2482PubMedCrossRefGoogle Scholar
  2. 2.
    Steinhauser KE, Clipp EC, McNeilly M et al (2000) In search of a good death: observations of patients, families and providers. Ann Intern Med 132:825–832PubMedGoogle Scholar
  3. 3.
    Walling A, Lorenz KA, Dy SM et al (2008) Evidence-based recommendations for information and care planning in cancer care. J Clin Oncol 26:3896–3902PubMedCrossRefGoogle Scholar
  4. 4.
    Grunier A, Mor V, Witzen S et al (2007) Where People Die: a multilevel approach to understanding influences on site of death in America. Med Care Res Rev 64:351–378CrossRefGoogle Scholar
  5. 5.
    Lorenz K, Lynn J, Dy S et al (2006) Quality measures for symptoms and advance care planning in cancer: a systematic review. J Clin Oncol 24:4933–4938PubMedCrossRefGoogle Scholar
  6. 6.
    Lorenz KA, Dy SM, Naeim A et al (2009) Quality measures for supportive cancer care: the cancer quality-ASSIST project. J Pain Symptom Manage 37:943–964PubMedCrossRefGoogle Scholar
  7. 7.
    Walling AM, Asch SM, Lorenz KA et al (2010) The quality of care provided to hospitalized patients at the end of life. Arch Intern Med 170:1057–1063PubMedCrossRefGoogle Scholar
  8. 8.
    Steinhauser KE, Christakis NA, Clipp EC et al (2001) Preparing for the end of life: preferences of patients, families, physicians, and other care providers. J Pain Symptom Manage 22:727–737PubMedCrossRefGoogle Scholar
  9. 9.
    Teno JM, Clarridge BR, Casey V et al (2004) Family perspectives on end-of-life care at the last place of care. JAMA 291:99–93CrossRefGoogle Scholar
  10. 10.
    Singer PA, Martin DK, Keiner M (1999) Quality end of life care: patients’ perspectives. JAMA 281:163–168PubMedCrossRefGoogle Scholar
  11. 11.
    Casarett D, Pickard A, Bailey E et al (2008) Do palliative consultations improve patient outcomes? J Am Geriatr Soc 56:593–599PubMedCrossRefGoogle Scholar
  12. 12.
    Wright AA, Zhang B, Ray A et al (2008) Association between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300(14):1665–1673PubMedCrossRefGoogle Scholar
  13. 13.
    Lautrette A, Darmon M, Megerbane B et al (2007) A communication strategy and brochure for relatives of patients dying in the ICU. N Eng J Med 356:469CrossRefGoogle Scholar
  14. 14.
    Higginson IJ, Finlay IG, Goodwin DM et al (2003) Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage 25:150–168PubMedCrossRefGoogle Scholar
  15. 15.
    Temel JS, Greer JA, Muzikansky A et al (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM 363:733–742PubMedCrossRefGoogle Scholar
  16. 16.
    Garrett JM, Harris RP, Norburn JK et al (1993) Life-sustaining treatments during terminal illness. Who wants what? J Gen Intern Med 8(7):361–368PubMedCrossRefGoogle Scholar
  17. 17.
    Pearlman RA, Cain KC, Starks H et al (2000) Preferences for life-sustaining treatments in advance care planning and surrogate decision making. J Palliat Med 3:37–48PubMedCrossRefGoogle Scholar
  18. 18.
    Luck J, Peabody JW, Dresselhaus TR et al (2000) How well does chart abstraction measure quality? Am J Med 108(8):642–649PubMedCrossRefGoogle Scholar
  19. 19.
    Glare P et al (2003) A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ 327:195–198PubMedCrossRefGoogle Scholar
  20. 20.
    Malin JL, O’Neill SM, Asch SM et al (2011) Quality of supportive care for patients with advanced cancer in a VA medical center. J Palliat Med 14:573–577PubMedCrossRefGoogle Scholar
  21. 21.
    Dy SM, Asch SM, Lorenz KA, Weeks K, Sharma RK, Wolff AC, Malin JL (2011) Quality of end-of-life care for patients with advanced cancer in an academic medical center. J Palliat Med 14:451–457PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag (outside the USA) 2012

Authors and Affiliations

  • Anne M. Walling
    • 1
    • 3
  • Steven M. Asch
    • 6
    • 7
  • Karl A. Lorenz
    • 3
    • 4
  • Jennifer Malin
    • 3
  • Carol P. Roth
    • 4
  • Tod Barry
    • 5
  • Neil S. Wenger
    • 1
    • 2
    • 4
  1. 1.Division of General Internal Medicine and Health Services Research, David Geffen School of MedicineUniversity of California, Los AngelesLos AngelesUSA
  2. 2.UCLA Health System Ethics CenterLos AngelesUSA
  3. 3.Greater Los Angeles Veterans Affairs Healthcare SystemLos AngelesUSA
  4. 4.RAND HealthSanta MonicaUSA
  5. 5.UCLA Center for Patient Safety and QualityLos AngelesUSA
  6. 6.VA Palo Alto Healthcare SystemPalo AltoUSA
  7. 7.Stanford School of MedicineStanfordUSA

Personalised recommendations