Palliative and end-of-life care in glioblastoma: defining and measuring opportunities to improve care

Abstract

Background: American Society for Clinical Oncology (ASCO) quality measures for terminal cancers recommend early advance care planning and hospice at the end of life. We sought to evaluate adherence to 5 palliative care quality measures and explore associations with patient outcomes in glioblastoma.

Methods: This is a retrospective analysis of 117 deceased glioblastoma patients over 5 years. Records were reviewed to describe adherence to palliative care quality measures and patient outcomes. Data regarding emotional assessments, advance directives, palliative care consultation, chemotherapy administration, hospice, location of death, and overall survival were collected.

Results: Median overall survival was 12.9 months. By the second oncology visit, 22.2% (26/117) had an emotional assessment completed. Advance directives were documented for 52.1% (61/117) by the third neuro-oncology visit (30/61 health care proxy), yet 26.5% (31/117) did not have any advance directive before the last month of life. With regard to other ASCO quality measures, 36.8% (43/117) had a palliative care consult; 94.0% (110/117) did not receive chemotherapy in the last 14 days of life; 59.8% (70/117) enrolled in hospice >7 days before death; and 56.4% (66/117) died in a home setting. Patients who enrolled in hospice >7 days before death were 3.56 times more likely to die in a home setting than patients enrolled <7 days before death or with no hospice enrollment (P = .002, [OR 3.56; 95% CI, 1.57-8.04]).

Conclusions: Late advance directive documentation, minimal early palliative care involvement, and the association of early hospice enrollment with death in a home setting underscore the need to improve care and better define palliative care quality measures in glioblastoma.

Keywords: advance directives; glioblastoma; hospice care; palliative care; quality improvement.

Fig. 1.

Location of death categorized by home setting vs health care facility. Abbreviations: CC, comfort care; ED, emergency department; SNF, skilled nursing facility; ICU, intensive care unit; IP, inpatient.

Fig. 2.

Kaplan–Meier analysis of time from hospice enrollment to death stratified by location of death (home setting vs health care facility).

Fig. 3.

Percentage of life after diagnosis spent without an advance directive or treatment-limiting order for each individual patient. (a) Advance Directive: 44/117 patients spent more than 80% of their survival without an advance directive. (b) Treatment-Limiting Order: 62/117 patients spent more than 90% of their survival without a treatment-limiting order.