Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
J Am Geriatr Soc. 2023 Nov;71(11):3546-3553. doi: 10.1111/jgs.18526. Epub 2023 Jul 29.
Studies examining end-of-life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG-I). We examine EOL care patterns across COG-I gradients, hypothesizing that greater COG-I severity is associated with lower odds of receiving aggressive EOL care.
Using data from the linked Surveillance Epidemiology and End Results (SEER) -Medicare -Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer-directed treatment, intensive care unit admission, >1 emergency department visit, or >1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between COG-I severity and receipt of aggressive EOL care.
Of the 40,833 patients in our study population, 49.2% were cognitively intact; 24.4% had mild COG-I; 19.7% had moderate COG-I; and 6.7% had severe COG-I. The percent of patients who received aggressive EOL care was 62.6% and 74.2% among those who were cognitively intact and those with severe COG-I, respectively. Compared with cognitively intact patients, those with severe COG-I had 86% higher odds of receiving any type of aggressive EOL care (adjusted odds ratio (aOR): 1.86 (95% confidence interval: 1.70-2.04)), which were primarily associated with higher odds of in-hospital death. The odds of in-hospital death associated with severe COG-I were higher among those with short- than with long-term stays (aOR:2.58 (2.35-2.84) and aOR:1.40 (1.17-1.67), respectively).
Contrary to our hypothesis, aggressive EOL care in older metastatic cancer patients with NFS was highest among those suffering severe COG-I. These findings can inform the development of interventions to help reduce aggressive EOL care in this patient population.
针对老年癌症患者临终关怀的研究很少，而且之前的研究没有考虑认知障碍（COG-I）的梯度。我们研究了 COG-I 梯度范围内的临终关怀模式，假设 COG-I 严重程度较高与接受积极的临终关怀的可能性较低相关。
我们使用来自链接的监测、流行病学和最终结果（SEER）-医疗保险-最低数据集（MDS）3.0 的数据，确定了在 2013 年至 2017 年期间有疗养院住院（NFS）和死于转移性癌症的患者。积极的临终关怀的标志是：癌症定向治疗、重症监护病房入院、在生命的最后 30 天内就诊超过 1 次急诊、或住院超过 1 次、临终前 3 天内入组临终关怀以及院内死亡。除了描述性分析外，我们还进行了多变量逻辑回归分析，以评估 COG-I 严重程度与接受积极的临终关怀之间的独立关联。
在我们的研究人群中，有 40833 名患者，其中 49.2%认知功能正常；24.4%有轻度 COG-I；19.7%有中度 COG-I；6.7%有重度 COG-I。接受积极的临终关怀的患者比例分别为认知功能正常患者的 62.6%和重度 COG-I 患者的 74.2%。与认知功能正常的患者相比，重度 COG-I 患者接受任何类型的积极临终关怀的可能性要高 86%（调整后的优势比（aOR）：1.86（95%置信区间：1.70-2.04）），这主要与院内死亡的可能性更高有关。与短期相比，与认知功能正常的患者相比，COG-I 严重程度与院内死亡的相关性在短期和长期住院患者中均更高（aOR：2.58（2.35-2.84）和 aOR：1.40（1.17-1.67））。
与我们的假设相反，患有 NFS 的老年转移性癌症患者的临终关怀最严重的是 COG-I 严重程度较高的患者。这些发现可以为开发干预措施提供信息，以帮助减少该患者群体中积极的临终关怀。
