Hospitalized patients with advanced malignancies often have high symptom burden and poor quality of life, which are frequently under-recognized or under-treated. Accordingly, the integration of specialty palliative care (PC) in this population is imperative. Unfortunately, a sustainable referral model to capture patients for timely PC involvement is lacking. This quality improvement study evaluated the implementation of a clinical trigger-based referral process to PC for inpatients on the Hematology/Oncology (HO) service at Hines VA Hospital. Clinical outcomes studied included: Life-Sustaining Treatment (LST) note completion rates; measurement of overall survival at 3, 6, and 12 months; rate of re-hospitalization within 30 days; and venue of death and treating specialty of deceased patients.
House staff received a weekly email that included the clinical PC triggers. Admitted patients who met trigger criteria would prompt consultation to PC. Clinical triggers included: metastatic oncologic disease or relapsed hematologic disease; uncontrolled symptoms; > 2 unscheduled hospitalizations in the prior 30 days; and unscheduled hospitalizations lasting > 7 days.
A total of 63 patients were admitted to the HO service between December 2020 through February 2021. Of those, 53 (84.1%) met at least 1 trigger and 36 (68%) received PC consultation. Of the patients that met trigger criteria and received a PC consult, 85.7% died with hospice compared to 44.4% in the group who did not receive a PC consult (P < .01). Nineteen (51.3%) died within 6 months of discharge compared to 7 (26.9%) who did not receive a PC consult (P = .08). Twelve (33.3%) had recurrent hospitalizations compared to 5 (29%) who did not receive a PC consult (P = .38), and 20 (55.6%) had a new or updated LST note compared to 2 (11.8%) who did not receive PC consultation (P < .01).
This study demonstrated the feasibility of implementing a trigger-based system for PC consultation in a veteran inpatient HO population. Notably, a large majority of HO inpatients met criteria for at least 1 PC trigger. No significant difference was found in overall survival at 6 months; however, patients who received PC consultation were more likely to receive hospice services at the end of life.