BACKGROUND: Limited data are available on how the timing and setting of palliative care (PC) referral can affect end‐of‐life care. In this retrospective cohort study, the authors examined how the timing and setting of PC referral were associated with the quality of end‐of‐life care.METHODS: All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had a PC consultation were included. Data were retrieved on PC referral and quality of end‐of‐life care indicators.RESULTS: Among 366 decedents, 120 (33%) had an early PC referral (>3 months before death), and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs 68%; P < .001), fewer hospitalizations (48% vs 81%; P < .003), and fewer hospital deaths (17% vs 31%; P = .004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs 68%; P < .001), fewer hospital admissions (52% vs 86%; P < .001), fewer hospital deaths (18% vs 34%; P = .001), and fewer intensive care unit admissions (4% vs 14%; P = .001). In multivariate analysis, outpatient PC referral (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.28‐0.66; P < .001) was independently associated with less aggressive end‐of‐life care. Men (OR, 1.63; 95% CI, 1.06‐2.50; P = .03) and hematologic malignancies (OR, 2.57; 95% CI, 1.18‐5.59; P = .02) were associated with more aggressive end‐of‐life care.CONCLUSIONS: Patients who were referred to outpatient PC had improved end‐of‐life care compared with those who received inpatient PC. The current findings support the need to increase the availability of PC clinics and to streamline the process of early referral. Cancer 2014;120:1743–1749. © 2014 American Cancer Society.

Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state‐of‐the‐science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team‐based, timely, and targeted palliative care. Team‐based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse‐led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00‐00. 2018 American Cancer Society, Inc.

BACKGROUND: To the authors' knowledge, only limited data are available regarding the quality of end‐of‐life care for patients with hematologic malignancies. In this retrospective cohort study, the quality of end‐of‐life care was compared between patients with hematologic malignancies and those with solid tumors.METHODS: All adult patients who died of advanced cancer between September 1, 2009 and February 28, 2010 while under the care of the study institution were included. The authors collected baseline demographics and end‐of‐life care indicators, including emergency room visits, hospitalization, intensive care unit admissions, and systemic cancer therapy use within the last 30 days of life.RESULTS: Of a total of 816 decedents, 113 (14%) had hematologic malignancies. In the last 30 days of life, patients with hematologic malignancies were more likely to have emergency room visits (54% vs 43%; P = .03), hospital admissions (81% vs 47%; P < .001), ≥ 2 hospital admissions (23% vs 10%; P < .001), > 14 days of hospitalization (38% vs 8%; P < .001), intensive care unit admissions (39% vs 8%; P < .001) and death (33% vs 4%; P < .001), chemotherapy use (43% vs 14%; P < .001), and targeted therapy use (34% vs 11%; P < .001) compared with patients with solid tumors. Patients with hematologic malignancies were also less likely to have palliative care unit admissions (8% vs 17%; P = .02). The composite score for aggressiveness of care (with 0 indicating the best and 6 indicating the worst) was significantly higher among patients with hematologic malignancies compared with those with solid tumors (median, 2 vs 0; P < .001). On multivariate analysis, hematologic malignancy was found to be a significant factor associated with aggressive end‐of‐life care (odds ratio, 6.6; 95% confidence interval, 4.1‐10.7 [P < .001]).CONCLUSIONS: The results of the current study indicate that patients with hematologic malignancies received more aggressive care at the end of life. Cancer 2014;120:1572–1578. © 2014 American Cancer Society.