Factors associated with the aggressiveness of care at the end of life for patients with cancer dying in hospital: a nationwide retrospective cohort study in mainland Portugal

Autores da FMUP

• Susana Isabel Oliveira Lopes

  Autor

• Nuno Miguel De Sousa Lunet

  Autor

Participantes de fora da FMUP

• Diogo, B
• Canario, R
• Freire, J
• Feio, M
• Ferraz Goncalves, J
• Sousa, G
• Gomes, B

Unidades de investigação

• Ciências da Saúde Pública e Forenses, e Educação Médica

• Medicina

Abstract

Introduction There is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL), defined as overly aggressive treatments that compromise the quality of life at its end. Recognising the most affected patients is a cornerstone to improve oncology care. Our aim is to identify factors associated with ACCEoL for patients with cancer dying in hospitals. Methods All adult patients with cancer who died in public hospitals in mainland Portugal (January 2010 to December 2015), identified from the hospital morbidity database. This database provided individual clinical and demographic data. We obtained hospital and region-level variables from a survey and National Statistics. The primary outcome is a composite ACCEoL measure of 16 indicators. We used multilevel random effects logistic regression modelling (p<0 center dot 05). Results We included 92 155 patients: median age 73 years; 62% male; 53% with metastatic disease. ACCEoL prevalence was 71% (95% CI 70% to 71%). The most prevalent indicators were >14 days in the hospital (43%, 42-43) and surgery (28%, 28-28) in the last 30 days. Older age (p<0 center dot 001), breast cancer (OR 0 center dot 83; 95% CI 0 center dot 76 to 0 center dot 91), and metastatic disease (0 center dot 54; 95% CI 0 center dot 50 to 0 center dot 58) were negatively associated with ACCEoL. In contrast, higher Deyo-Charlson Comorbidity Index (p<0 center dot 001), gastrointestinal and haematological malignancies (p<0 center dot 001), and death at cancer centre (1 center dot 31; 95% CI 1 center dot 01 to 1 center dot 72) or hospital with medical oncology department (1 center dot 29; 95% CI 1 center dot 02 to 1 center dot 63) were positively associated with ACCEoL. There was no association between hospital palliative care services at the hospital of death and ACCEoL. Conclusion Clinical factors related to a better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and gastrointestinal malignancies might represent groups with complex needs, and haematological patients may be at increased risk because of unpredictable prognosis. Improvement of hospital palliative care services could help reduce ACCEoL, particularly in cancer centres and hospitals with medical oncology department, as those services are usually under-resourced, thus reaching few.

Keywords

• neoplasms; palliative care; terminal care; hospital mortality; risk factors