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. 2023 Nov;71(11):3546-3553.
doi: 10.1111/jgs.18526. Epub 2023 Jul 29.

Aggressive end-of-life care across gradients of cognitive impairment in nursing home patients with metastatic cancer

Siran M Koroukian  1   2 , Sara L Douglas  2   3 , Long Vu  1 , Hannah L Fein  1 , Richa Gairola  4 , David F Warner  5   6 , Nicholas K Schiltz  3 , Jennifer Cullen  1   2 , Cynthia Owusu  2   7 , Martha Sajatovic  8 , Johnie Rose  1   2   9
Affiliations

Aggressive end-of-life care across gradients of cognitive impairment in nursing home patients with metastatic cancer

Siran M Koroukian et al. J Am Geriatr Soc. 2023 Nov.

Abstract

Background: Studies examining end-of-life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG-I). We examine EOL care patterns across COG-I gradients, hypothesizing that greater COG-I severity is associated with lower odds of receiving aggressive EOL care.

Methods: Using data from the linked Surveillance Epidemiology and End Results (SEER) -Medicare -Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer-directed treatment, intensive care unit admission, >1 emergency department visit, or >1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between COG-I severity and receipt of aggressive EOL care.

Results: Of the 40,833 patients in our study population, 49.2% were cognitively intact; 24.4% had mild COG-I; 19.7% had moderate COG-I; and 6.7% had severe COG-I. The percent of patients who received aggressive EOL care was 62.6% and 74.2% among those who were cognitively intact and those with severe COG-I, respectively. Compared with cognitively intact patients, those with severe COG-I had 86% higher odds of receiving any type of aggressive EOL care (adjusted odds ratio (aOR): 1.86 (95% confidence interval: 1.70-2.04)), which were primarily associated with higher odds of in-hospital death. The odds of in-hospital death associated with severe COG-I were higher among those with short- than with long-term stays (aOR:2.58 (2.35-2.84) and aOR:1.40 (1.17-1.67), respectively).

Conclusions: Contrary to our hypothesis, aggressive EOL care in older metastatic cancer patients with NFS was highest among those suffering severe COG-I. These findings can inform the development of interventions to help reduce aggressive EOL care in this patient population.

Keywords: aggressive end-of-life care; metastatic cancer; nursing home status.

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Conflict of interest statement

Conflicts of interest: None

Figures

Figure 1:
Figure 1:
Unadjusted and Adjusted Odds Ratios for Markers of Aggressive End-of-Life Care by Levels of Cognitive Impairment
See this image and copyright information in PMC

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