Illness Understanding, Prognostic Awareness, and End-of-Life Care in Patients With GI Cancer and Malignant Bowel Obstruction With Drainage Percutaneous Endoscopic Gastrostomy.

PURPOSE: Malignant bowel obstruction (MBO) is common in advanced GI cancer, and MBO management, including drainage percutaneous endoscopic gastrostomy (dPEG), is palliative. How patients understand the goals of dPEG and its impact on disease is inadequately understood in the literature. Therefore, we analyzed these issues in patients with GI cancer. METHODS: Demographics, clinical variables, and patient outcomes were abstracted from the medical record. Illness understanding and future expectations were retrieved from palliative care notes. We described additional treatment and outcomes after dPEG and estimated overall survival (OS). RESULTS: From January 2015 to June 2017, 125 admitted patients with metastatic GI cancer underwent dPEG for MBO. Cancers were most commonly colorectal (34%) and pancreatic/ampullary (25%). During the dPEG admission, 32% (40 of 125) of patients had a palliative care consultation, and 22% (28 of 125) were asked about illness understanding and future expectations. All (28 of 28) reported good understanding of the advanced nature of their disease, but few were accurate about prognosis given their stage IV disease (10 of 28). Of the 117 (94%) discharged, 13% (15 of 117) received additional chemotherapy, which rarely prevented progression; half (63 of 117) had a do-not-resuscitate order; and most (101 of 117) were enrolled in hospice at death. Median time to death was 37 days (95% CI, 29 to 45 days); 6-month OS was 3.7% (95% CI, 1.2% to 8.4%). CONCLUSION: dPEGs are placed close to end of life in patients with advanced GI cancer. A minority of patients receive additional chemotherapy post-dPEG. Many have adequate disease understanding, but chemotherapy benefit is low, and future expectations vary. This may be an opportunity for improved communication regarding palliative procedures in advanced cancer.

Resource Utilization in Hospitalized Patients With Cancer From Hospice Decision to Discharge and Provider-Type Differences.

Aggressive resource utilization for patients with cancer at the end of life has been associated with poor outcomes for patients and their families. To our knowledge, no previous studies have characterized resource utilization as a proxy for quality end-of-life care in hospitalized patients awaiting discharge to hospice by physician and advanced practice providers (APPs). We conducted a retrospective cohort study to examine resource utilization and the quality metrics for end-of-life care in patients at Memorial Sloan Kettering Cancer Center from the date of hospice decision to discharge. Patients under the care of APP teams were less likely to receive laboratory testing (50% vs 59%, P = .046) and received fewer tests than those with house staff teams, though performance on end-of-life quality metrics was similar. Our findings suggest APPs may improve quality of end-of-life care by avoiding unnecessary or aggressive measures compared to house staff.

Drainage Percutaneous Endoscopic Gastrostomy for Malignant Bowel Obstruction in Gastrointestinal Cancers: Prognosis and Implications for Timing of Palliative Intervention.

BACKGROUND: Malignant bowel obstruction (MBO) is a frequent complication in patients with advanced solid tumors. Palliative relief may be achieved by the use of a drainage percutaneous endoscopic gastrostomy (dPEG) tube, although optimal timing of placement remains unknown. OBJECTIVES: To determine median survival after diagnosis of MBO and dPEG placement, factors associated with worse survival in MBO, factors associated with receipt of dPEG, and association of timing of dPEG placement on survival. METHODS: This observational retrospective cohort study examined 439 patients with MBO on a gastrointestinal medical oncology inpatient service. Patients were characterized by age, gender, race, primary cancer type, length of stay, readmission, complications (aspiration pneumonia or bowel perforation), and receipt of dPEG. Select factors were analyzed to examine overall survival (OS) and dPEG placement. RESULTS: Median survival from diagnosis of first MBO was 2.5 months. Median survival after dPEG placement was 37 days. In univariate analysis, dPEG placement, complications, longer length of stay, and readmissions were significantly associated with worse OS. Receipt of dPEG was significantly associated with younger age, longer length of stay at first admission, and shorter interval to readmission. In patients who received dPEG, longer interval from MBO diagnosis to dPEG placement did not affect OS. CONCLUSION: We found that prognosis following diagnosis of MBO in patients with gastrointestinal malignancies remains poor. Our data suggest that timing of dPEG placement in MBO does not affect OS and, therefore, earlier intervention with this procedure may allow earlier and prolonged palliative relief.

Hospitalists caring for patients with advanced cancer: An experience-based guide.

Every year, nearly 5 million adults with cancer are hospitalized. Limited evidence suggests that hospitalization of the cancer patient is associated with adverse morbidity and mortality. Hospitalization of the patient with advanced cancer allows for an intense examination of health status in the face of terminal illness and an opportunity for defining goals of care. This experience-based guide reports what is currently known about the topic and outlines a systematic approach to maximizing opportunities, improving quality, and enhancing the well-being of the hospitalized patient with advanced cancer.

Hospitalists on an inpatient tertiary care oncology teaching service.

PURPOSE: Hospitalists provide quality care in various inpatient settings, but the ability of hospitalists to provide quality inpatient care for patients with complex cancer has not been studied. This study explores outcomes with a hospitalist-led versus medical oncologist-led house staff team on an inpatient medical GI oncology teaching service. METHODS: This observational retrospective cohort study examined 829 patient discharges from August 2012 to January 2013 on the GI oncology inpatient teaching service at Memorial Sloan Kettering Cancer Center, a tertiary cancer center in New York, New York. We compared average length of stay (ALOS), 30-day readmission rates, establishment of new do not resuscitate (DNR) orders, nosocomial pneumonia and urinary tract infection (UTI) rates, radiographic and laboratory tests per patient, and disposition on discharge between hospitalist-led and oncologist-led teams. RESULTS: Median years of clinical experience was 6 (range, 4 to 9 years) for hospitalists and 7 (range, 0.5 to 36 years) for oncologists. ALOS (hospitalist led, 5.6 v oncologist led, 5.2 days; P = .30), readmission within 30 days (hospitalist led, 14% v oncologist led, 16%; P = .44), new DNR orders (hospitalist led, 18% v oncologist led, 19%; P = .90), nosocomial pneumonia (hospitalist led, 0.5% v oncologist led, 0.7%; P = .63) and UTI rates (hospitalist led, 0.5% v oncologist led, 0.7%; P = .63), number of radiographic studies and laboratory tests, and disposition on discharge were not significantly different between groups. CONCLUSION: A hospitalist-led inpatient service with house staff represents a novel approach for caring for hospitalized GI oncology patients with cancer.

30-day-or-sooner readmissions of gastrointestinal medical oncology patients following cancer center inpatient service discharge: characteristics and preventability.

PURPOSE: The Centers for Medicare and Medicaid Services recently initiated readmission reduction programs for certain noncancer index admissions. Intrinsic to this policy is the assumption that such readmissions are reasonably preventable and are due to inadequate management. For cancer patients, readmission frequency, characteristics, and their preventability have not been extensively evaluated. METHODS: We first electronically searched medical records of patients on our gastrointestinal oncology inpatient service to identify patients who had been discharged and then readmitted within 30 days. However, electronic review resulted in insufficient granularity of clinical records. Therefore, 50 of them were randomly selected for exhaustive manual review to assess the reasons for index admission and readmission, the nature of the index admission discharge plan, and whether the readmission was reasonably preventable or not, based on prespecified criteria. RESULTS: Between September 1, 2008, and March 1, 2013, 3995 gastrointestinal medical oncology patients had an index admission, of whom 876 (22%) had ≥ 1 readmission within 30 days. From the 50 manually reviewed records, the most common diagnosis categories for either the index admission or the readmission were infection, pain, and gastrointestinal issues. For 64% of these patients, the diagnoses of the index admission and the readmission were different. Disagreement between the care team and patient/family about the index admission discharge plan was documented in 10%. The readmission was determined to be preventable in 1 (2%) of the 50 manually reviewed cases. CONCLUSIONS: Readmissions in this cancer population are common and reflect the refractory nature of these diseases and the high disease burdens. The vast majority of readmissions in this population, by our criteria, were not preventable. Our ongoing research in this vulnerable population includes efforts to better characterize and communicate care options, especially in the cases in which there was disagreement between the care team and patient/family.

Administration of human inter-alpha-inhibitors maintains hemodynamic stability and improves survival during sepsis.

OBJECTIVES: The major forms of human inter-alpha-inhibitor proteins circulating in the plasma are inter-alpha-inhibitor (IalphaI, containing one light peptide chain called bikunin and two heavy chains) and pre-alpha-inhibitor (PalphaI, containing one light and one heavy chain). Although it has been reported that a decrease in IalphaI/PalphaI is correlated with an increased mortality rate in septic patients, it remains unknown whether administration of IalphaI/PalphaI early after the onset of sepsis has any beneficial effects on the cardiovascular response and outcome of the septic animal. The aim of this study, therefore, was to determine whether IalphaI and PalphaI have any salutary effects on the depressed cardiovascular function, liver damage, and mortality rate after polymicrobial sepsis. DESIGN: Prospective, controlled, randomized animal study. SETTING: A university research laboratory. SUBJECTS: Male adult rats were subjected to polymicrobial sepsis by cecal ligation and puncture or sham operation followed by the administration of normal saline (i.e., resuscitation). MEASUREMENTS AND MAIN RESULTS: At 1 hr after cecal ligation and puncture, human IalphaI/PalphaI at a dose of 30 mg/kg body weight or vehicle (normal saline, 1 mL/rat) were infused intravenously over a period of 30 mins. At 20 hrs after cecal ligation and puncture (i.e., the late, hypodynamic stage of sepsis), cardiac output was measured by using a dye dilution technique, and blood samples were collected for assessing oxygen content. Oxygen delivery, consumption, and extraction ratio were determined. Plasma concentrations of liver enzymes alanine aminotransferase and aspartate aminotransferase as well as lactate and tumor necrosis factor-alpha also were measured. In additional animals, the necrotic cecum was excised at 20 hrs after cecal ligation and puncture with or without IalphaI/PalphaI treatment, and survival was monitored for 10 days thereafter. The results indicate that administration of human IalphaI/PalphaI early after the onset of sepsis maintained cardiac output and systemic oxygen delivery, whereas it increased oxygen consumption and extraction at 20 hrs after cecal ligation and puncture. The elevated concentrations of alanine aminotransferase, aspartate aminotransferase, tumor necrosis factor-alpha, and lactate were attenuated by IalphaI/PalphaI treatment. In addition, administration of human IalphaI/PalphaI improved the survival rate from 30% to 89% in septic animals at day 10 after cecal ligation and puncture and cecal excision. CONCLUSION: Human IalphaI/PalphaI appears to be a useful agent for maintaining hemodynamic stability and improving survival during the progression of polymicrobial sepsis.