Association between Early Palliative Care Referrals, Inpatient Hospice Utilization, and Aggressiveness of Care at the End of Life

Background: Palliative care has a positive effect on many clinical outcomes, yet most referrals to palliative care have occurred late. End-of-life (EOL) cancer care has become increasingly aggressive. There have been no studies investigating the association between early palliative care referrals and aggressive EOL care in Japan. Objective: This study was designed to explore the association between early palliative care referrals, inpatient hospice utilization, and aggressiveness of EOL care by investigating cancer decedents. Design: A retrospective cohort study in a cancer-designated hospital in Japan. Setting/Subjects: This study examined 266 consecutive cancer decedents. Inclusion criteria were adults and patients who died from cancer or causes related to cancer. Patients who died from causes unrelated to cancer were excluded. A total of 265 patients met the criteria. Measurements: We explored the association between early referrals (>3 months before death) and inpatient hospice utilization and the relationship between the timing of referrals and aggressive EOL care measured by a composite score adapted from Earle and colleagues. Results: Patients were divided into an early referral group (n=54) and a control group (n=211). The rate of inpatient hospice utilization was significantly higher in the early referral group (74% versus 47%, adjusted p<0.001). While each of six indicators of aggressiveness of EOL care did not differ significantly, the composite score was significantly lower in the early referral group (1.91 +/- 0.59 versus 2.14 +/- 0.78, adjusted p<0.001). Conclusions: Early palliative referrals were associated with more inpatient hospice utilization and less aggressive EOL care.