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Context Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear. Objective To determine the prevalence of TIP visiting the ED. Methods Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle–Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I2). Results We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37–54%] and 75% in the last six months of life [95% CI 62–83%]; I2 = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12–23%]; I2 = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping. Conclusions Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.

Summary Background The role of neuroleptics for terminal agitated delirium is controversial. We assessed the effect of three neuroleptic strategies on refractory agitation in patients with cancer with terminal delirium. Methods In this single-centre, double-blind, parallel-group, randomised trial, patients with advanced cancer, aged at least 18 years, admitted to the palliative and supportive care unit at the University of Texas MD Anderson Cancer Center (Houston, TX, USA), with refractory agitation, despite low-dose haloperidol, were randomly assigned to receive intravenous haloperidol dose escalation at 2 mg every 4 h, neuroleptic rotation with chlorpromazine at 25 mg every 4 h, or combined haloperidol at 1 mg and chlorpromazine at 12·5 mg every 4 h, until death or discharge. Rescue doses identical to the scheduled doses were administered at inception, and then hourly as needed. Permuted block randomisation (block size six; 1:1:1) was done, stratified by baseline Richmond Agitation Sedation Scale (RASS) scores. Research staff, clinicians, patients, and caregivers were masked to group assignment. The primary outcome was change in RASS score from time 0 to 24 h. Comparisons among group were done by modified intention-to-treat analysis. This completed study is registered with ClinicalTrials.gov , NCT03021486 . Findings Between July 5, 2017, and July 1, 2019, 998 patients were screened for eligibility, with 68 being enrolled and randomly assigned to treatment; 45 received the masked study interventions (escalation n=15, rotation n=16, combination n=14). RASS score decreased significantly within 30 min and remained low at 24 h in the escalation group (n=10, mean RASS score change between 0 h and 24 h −3·6 [95% CI −5·0 to −2·2]), rotation group (n=11, −3·3 [–4·4 to −2·2]), and combination group (n=10, −3·0 [–4·6 to −1·4]), with no difference among groups (p=0·71). The most common serious toxicity was hypotension (escalation n=6 [40%], rotation n=5 [31%], combination n=3 [21%]); there were no treatment-related deaths. Interpretation Our data provide preliminary evidence that the three strategies of neuroleptics might reduce agitation in patients with terminal agitation. These findings are in the context of the single-centre design, small sample size, and lack of a placebo-only group. Funding National Institute of Nursing Research.

Introduction. The desire to hasten death (DHD) might be present in patients with advanced cancer. Multiple distressing physical and psychosocial symptoms may be related to it. There is limited literature about the characteristics of these patients in Mexico. Objective. To describe the prevalence and factors associated with DHD in advanced cancer patients evaluated by a palliative care psychiatrist. Method. We conducted a cross-sectional study, including all patients referred to psychiatric assessment at the Servicio de Cuidados Paliativos of the Instituto Nacional de Cancerologia in Mexico City, from January to December 2016. DHD was defined as the presence of death ideas, suicidal ideation, and/or request for euthanasia or medically assisted suicide. Patients with delirium, dementia, psychosis, or uncontrolled physical symptoms were excluded. Results. Sixty-four patients were included in the study. Most of them were women (59%); the mean age was 49 years old ( SD = 16). Of them, 64% met criteria for a major depressive disorder, 64% for generalized anxiety disorder and/or panic disorder, and 11% for substance use disorders. 44% expressed DHD. In a multivariate regression analysis predicting DHD, only one factor emerged: clinical depression ( OR = 13.5, p = .002, 95% CI [02.562, 71.726]). Discussion and conclusion. The desire to hasten death is a frequent issue for the patients evaluated at the psychiatric palliative care clinic. Depression and other distressing psychiatric pathologies were associated with DHD. Interdisciplinary interventions are needed to treat DHD. More research is warranted in order to understand the factors associated with the expression of DHD.

BACKGROUND. Financial distress (FD) is common among patients with advanced cancer. Our purpose was to compare the frequency and intensity of FD and its associations with symptom distress and quality of life (QOL) in these patients in France and the U.S. MATERIALS AND METHODS. In this secondary analysis of two cross‐sectional studies, we assessed data on 292 patients who received cancer care at a public hospital or a comprehensive cancer center in France (143 patients) or the U.S. (149 patients). Outpatients and hospitalized patients over 18 years of age with advanced lung or breast or colorectal or prostate cancer were included. Diagnosed cognitive disorder was considered a noninclusion criterion. Advanced cancer included relapse or metastasis or locally advanced cancer or at least a second‐line chemotherapy regimen. Patients self‐rated FD and assessed symptoms, psychosocial distress, and QOL on validated questionnaires. RESULTS. The average patient age was 59 years, and 144 (49%) were female. FD and high intensity were reported more frequently in U.S. patients than in French (respectively 129 [88%] vs. 74 [52%], p

Background: Cancer patients frequently use complementary and alternative medicine (CAM), and spirituality has been associated with CAM use among patients. We evaluated how oncologists’ spirituality and religiosity are associated with personal use and patient recommendations for CAM. Methods: A survey was mailed to 1000 medical oncologists in the United States. The questionnaire asked about oncologists’ approaches to CAM use by patients, focusing on the use of herbs and supplement (HS), and about religiosity and spirituality. Results: Of 937 deliverable questionnaires, 392 were returned (response rate 42%). Respondents were mostly men (71%) and Caucasian (76%), with a median age of 48. Approximately 16% reported no religion, 19% Jewish, 24% Catholic, 28% Christian, and 13% other religions. Eighteen percent reported attending religious services at least once a week, including 15% who attend several times per week. Twenty-eight percent reported high theological pluralism (skepticism regarding whether one religion is comprehensively and uniquely true); 58% described themselves as moderately or very spiritual. Self-reported spirituality and religious service attendance were associated with using CAM personally and recommending HS to patients. In multivariate analyses, moderate-high spirituality and attending religious services less than monthly was positively associated with personal use of CAM: odds ratio (OR) = 3.10 (confidence interval [CI] = 1.5-6.5) and OR = 3.04 (CI = 1.5-6.6), respectively. Physicians with moderate to high spirituality were more likely to report recommending CAM in general (OR = 3.07, CI = 1.3-7.1), but less likely to report recommending HS (OR = 0.33, CI = 0.14-0.75). Conclusion: Self-reported spirituality is a significant factor among US oncologists’ decision to use CAM and recommend CAM to patients.

Conversations about end-of-life (EOL) wishes are challenging for many clinicians. The Go Wish card game (GWG) was developed to facilitate these conversations. Little is known about the type and consistency of EOL wishes using the GWG in advanced cancer patients. We conducted a randomized controlled trial to assess the EOL wishes of 100 patients with advanced cancer treated at The University of Texas MD Anderson Cancer Center. The purpose of this study was to determine the EOL wishes of patients with advanced cancer and to compare patients’ preference between the GWG and List of wishes/statements (LOS) containing the same number of items. Patients were randomized into four groups and completed either the GWG or a checklist of 35 LOS and one opened statement found on the GWG cards; patients were asked to categorize these wishes as very, somewhat, or not important. After 4–24 h, the patients were asked to complete the same or other test. Group A (n = 25) received LOS-LOS, group B (n = 25) received GWG-GWG, group C (n = 26) received GWG-LOS, and group D (n = 24) received LOS-GWG. All patients completed the State-Trait Anxiety Inventory (STAI) for adults before and after the first test. Median age (interquartile range = IQR): 56 (27–83) years. Age, sex, ethnicity, marital status, religion, education, and cancer diagnosis did not differ significantly among the four groups. All patients were able to complete the GWG and/or LOS. The ten most common wishes identified as very important by patients in the first and second test were to be at peace with God (74 vs. 71 %); to pray (62 vs. 61 %); and to have family present (57 vs. 61 %). to be free from pain (54 vs. 60 %); not being a burden to my family (48 vs. 49 %); to trust my doctor (44 vs. 45 %); to keep my sense of humor (41 vs. 45 %); to say goodbye to important people in my life (41 vs. 37 %); to have my family prepared for my death (40 vs. 49 %); and to be able to help others (36 vs. 31 %). There was significant association among the frequency of responses of the study groups. Of the 50 patients exposed to both tests, 43 (86 %) agreed that the GWG instructions were clear, 45 (90 %) agreed that the GWG was easy to understand, 31 (62 %) preferred the GWG, 39 (78 %) agreed that the GWG did not increase their anxiety and 31 (62 %) agreed that having conversations about EOL priorities was beneficial. The median STAI score after GWG was 48 (interquartile range, 39–59) vs. 47 (interquartile range, 27–63) after LOS (p = 0.2952). Patients with advanced cancer assigned high importance to spirituality and the presence/relationships of family, and these wishes were consistent over the two tests. The GWG did not worsen anxiety.

Background: Patients with advanced cancer experience severe physical, psychosocial, and spiritual distress requiring palliative care (PC). There are limited literature regarding characteristics and outcomes of patients evaluated by PC services at public hospitals (PHs). Objective, Design, Setting/Subjects, and Measurements: To compare the outcomes of advanced cancer patients undergoing PC at a PH and those at a comprehensive cancer center (CCC). We reviewed 359 consecutive advanced cancer patients (PH, 180; CCC, 179) undergoing PC. Symptoms and outcomes at consultation and first follow-up visit were assessed. Summary statistics were used to describe patient characteristics and outcomes. Results: The PH and CCC patients differed significantly according to race: 23% white, 39% black, and 36% Hispanic patients at the PH versus 66% white, 17% black, and 11% Hispanic patients at the CCC (p

Objective:Regular assessments of spiritual distress/spiritual pain among patients in a supportive/palliative care clinic (SCPC) are limited or unavailable. We modified the Edmonton Symptom Assessment Scale (ESAS) by adding spiritual pain (SP) to the scale (0 = best, 10 = worst) to determine the frequency, intensity, and correlates of self-reported SP (≥1/10) (pain deep in your soul/being that is not physical) among these advanced cancer patients.Method:We reviewed 292 consecutive consults of advanced cancer patients (ACPs) who were evaluated at our SCPC between October of 2012 and January of 2013. Symptoms were assessed using the new instrument (termed the ESAS–FS).Results:The median age of patients was 61 (range = 22–92). Some 53% were male; 189 (65%) were white, 45 (15%) African American, and 34 (12%) Hispanic. Some 123 of 282 (44%) of ACPs had SP (mean (95% CI) = 4(3.5–4.4). Advanced cancer patients with SP had worse pain [mean (95% CI) = 5.3(4.8, 5.8) vs. 4.5(4.0, 5.0)] (p = 0.02); depression [4.2(3.7, 4.7) vs. 2.1(1.7, 2.6), p < 0.0001]; anxiety [4.2(3.6, 4.7) vs. 2.5(2.0, 3.0), p < 0.0001]; drowsiness [4.2(3.7, 4.7) vs. 2.8(2.3, 3.2), p < 0.0001]; well-being [5.4(4.9, 5.8) vs. 4.5(4.1, 4.9), p = 0.0136]; and financial distress (FD) [4.4(3.9, 5.0) vs. 2.2(1.8, 2.7), p < 0.0001]. Spiritual pain correlated (Spearman) with depression (r = 0.45, p < 0.0001), anxiety (r = 0.34, p < 0.0001), drowsiness (r = 0.26, p < 0.0001), and FD (r = 0.44, p < 0.0001). Multivariate analysis showed an association with FD [OR (95% Wald CI) = 1.204(1.104–1.313), p < 0.0001] and depression [1.218(1.110–1.336), p < 0.0001]. The odds that patients who had SP at baseline would also have SP at follow-up were 182% higher (OR = 2.82) than for patients who were SP-negative at baseline (p = 0.0029). SP at follow-up correlated with depression (r = 0.35, p < 0.0001), anxiety (r = 0.25, p = 0.001), well-being (r = 0.27, p = 0.0006), nausea (r = 0.29, p = 0.0002), and financial distress (r = 0.42, p < 0.0001).Significance of results:Spiritual pain, which is correlated with physical and psychological distress, was reported in more than 40% of ACPs. Employment of the ESAS–FS allows ACPs with SP to be identified and evaluated in an SCPC. More research is needed.

Objective. There are limited data on the effects of financial distress (FD) on overall suffering and quality of life (QOL) of patients with advanced cancer (AdCa). In this cross-sectional study, we examined the frequency of FD and its correlates in AdCa. Patients and Methods. We interviewed 149 patients, 77 at a comprehensive cancer center (CCC) and 72 at a general public hospital (GPH). AdCa completed a self-rated FD (subjective experience of distress attributed to financial problems) numeric rating scale (0 = best, 10 = worst) and validated questionnaires assessing symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial distress (Hospital Anxiety and Depression Scale [HADS]), and QOL (Functional Assessment of Cancer Therapy-General [FACT-G]). Results. The patients’ median age was 60 years (95% confidence interval [CI]: 58.6–61.5 years); 74 (50%) were female; 48 of 77 at CCC (62%) versus 13 of 72 at GPH (18%) were white; 21 of 77 (27%) versus 32 of 72 (38%) at CCC and GPH, respectively, were black; and 7 of 77 (9%) versus 27 of 72 (38%) at CCC and GPH, respectively, were Hispanic (p < .0001). FD was present in 65 of 75 at CCC (86%; 95% CI: 76%–93%) versus 65 of 72 at GPH (90%; 95% CI: 81%–96%; p = .45). The median intensity of FD at CCC and GPH was 4 (interquartile range [IQR]: 1–7) versus 8 (IQR: 3–10), respectively (p = .0003). FD was reported as more severe than physical distress, distress about physical functioning, social/family distress, and emotional distress by 45 (30%), 46 (31%), 64 (43%), and 55 (37%) AdCa, respectively (all significantly worse for patients at GPH) (p < .05). AdCa reported that FD was affecting their general well-being (0 = not at all, 10 = very much) with a median score of 5 (IQR: 1–8). FD correlated (Spearman correlation) with FACT-G (r = −0.23, p = .0057); HADS-anxiety (r = .27, p = .0014), ESAS-anxiety (r = .2, p = .0151), and ESAS-depression (r = .18, p = .0336). Conclusion. FD was very frequent in both groups, but median intensity was double among GPH patients. More than 30% of AdCa rated FD to be more severe than physical, family, and emotional distress. More research is needed to better characterize FD and its correlates in AdCa and possible interventions. Implications for Practice: Financial distress is an important and common factor contributing to the suffering of advanced cancer patients and their caregivers. It should be suspected in patients with persistent, refractory symptom expression. Early identification, measurement, and documentation will allow clinical teams to develop interventions to improve financial distress and its impact on quality of life of advanced cancer patients.

Objective:The potential influence of patient religious and spiritual beliefs on the approach to end-of-life care and resuscitation status preferences is not well understood. The aim of this study was to assess the association between religiosity and resuscitation preferences in advanced-cancer patients.Method:We performed a secondary analysis of a randomized controlled trial that evaluated the influence of physician communication style on patient resuscitation preferences. All patients completed the Santa Clara Strength of Religious Faith Questionnaire–Short Form (SCSRFQ–SF) and expressed their resuscitation preferences. We determined the frequency of resuscitation preferences and its association with intensity of religiosity.Results:A total of 78 patients completed the study. The median age was 54 years, with a range of 18–78. Some 46 (59%) were women; 57 patients (73%) were Caucasian, 15 (19%) African American, and 5 (7%) Hispanic. A total of 46 patients (56%) were Protestant and 13 (17%) Catholic. Some 53 of 60 patients who chose Do Not Resuscitate status (DNR) (88%) and 16 of 18 patients who refused DNR (89%) for a video-simulated patient were highly religious (p = 0.64). When asked about a DNR for themselves after watching the videos, 43 of 48 who refused DNR (90%) and 26 of 30 patients who chose DNR (87%) were highly religious (p = 0.08). The Spearman correlation coefficient for patients choosing DNR for themselves and intensity of religiosity was r = –0.16 (p = 0.16). Some 30 patients (38%) who chose DNR for the video patient refused DNR for themselves, and 42 who chose DNR for both the video patient and themselves (54%) were highly religious (p = NS).Significance of Results:There was no significant association between intensity of patient religiosity and DNR preference for either the video patient or the patients themselves. Other beliefs and demographic factors likely impact end-of-life discussions and resuscitation status preferences.

Background Elevated resting energy expenditure (REE) may contribute to weight loss and symptom burden in cancer patients. Aims The aim of this study was to compare the velocity of weight loss, symptom burden (fatigue, insomnia, anxiety, and anorexia—combined score as measured by the Edmonton Symptom Assessment Score), high-sensitivity C-reactive protein, and survival among cancer patients referred to a cachexia clinic with hypermetabolism, elevated REE > 110% of predicted, with normal REE. Methods A retrospective analysis of 60 advanced cancer patients evaluated in a cachexia clinic for either >5% weight loss or anorexia who underwent indirect calorimetry to measure REE. Patients were dichotomized to either elevated or normal REE. Descriptive statistics were generated, and a two-sample Student's t-tests were used to compare the outcomes between the groups. Kaplan–Meier and Cox regression methodology were used to examine the survival times between groups. Results Thirty-seven patients (62%) were men, 41 (68%) were White, 59 (98%) solid tumours, predominantly 23 gastrointestinal cancers (38%), with a median age of 60 (95% confidence interval 57.0–62.9). Thirty-five patients (58%) were hypermetabolic. Non-Caucasian patients were more likely to have high REE [odds ratio = 6.17 (1.56, 24.8), P = 0.01]. No statistical difference regarding age, cancer type, gender, active treatment with chemotherapy, and/or radiation between hypermetabolic and normal REE was noted. The velocity of weight loss over a 3 month period (−8.5 kg vs. −7.2 kg, P = 0.68), C-reactive protein (37.3 vs. 55.6 mg/L, P = 0.70), symptom burden (4.2 vs. 4.5, P = 0.54), and survival (288 vs. 276 days, P = 0.68) was not significantly different between high vs. normal REE, respectively. Conclusion Hypermetabolism is common in cancer patients with weight loss and noted to be more frequent in non-Caucasian patients. No association among velocity of weight loss, symptom burden, C-reactive protein, and survival was noted in advanced cancer patients with elevated REE.

BACKGROUND A high frequency of hypogonadism has been reported in male patients with advanced cancer. The current study was performed to evaluate the association between low testosterone levels, symptom burden, and survival in male patients with cancer. METHODS Of 131 consecutive male patients with cancer, 119 (91%) had an endocrine evaluation of total (TT), free (FT), and bioavailable testosterone (BT); high-sensitivity C-reactive protein (CRP); vitamin B12; thyroid-stimulating hormone; 25-hydroxy vitamin D; and cortisol levels when presenting with symptoms of fatigue and/or anorexia-cachexia. Symptoms were evaluated by the Edmonton Symptom Assessment Scale. The authors examined the correlation using the Spearman test and survival with the log-rank test and Cox regression analysis. RESULTS The median age of the patients was 64 years; the majority of patients were white (85 patients; 71%). The median TT level was 209 ng/dL (normal: ≥ 200 ng/dL), the median FT was 4.4 ng/dL (normal: ≥ 9 ng/dL), and the median BT was 22.0 ng/dL (normal: ≥ 61 ng/dL). Low TT, FT, and BT values were all associated with worse fatigue (P ≤ .04), poor Eastern Cooperative Oncology Group performance status (P ≤ .05), weight loss (P ≤ .01), and opioid use (P ≤ .005). Low TT and FT were associated with increased anxiety (P ≤ .04), a decreased feeling of well-being (P ≤ .04), and increased dyspnea (P ≤ .05), whereas low BT was only found to be associated with anorexia (P = .05). Decreased TT, FT, and BT values were all found to be significantly associated with elevated CRP and low albumin and hemoglobin. On multivariate analysis, decreased survival was associated with low TT (hazards ratio [HR], 1.66; P = .034), declining Eastern Cooperative Oncology Group performance status (HR, 1.55; P = .004), high CRP (HR, 3.28; P

164 Background: Spirituality (S) and religiosity (R) are essential in delivering Quality Palliative Care(PC). There's limited literature regarding Latin American clinicians’ spiritual and religious characteristics, or how these shape their clinical engagement and presence of burnout. Methods: To describe the frequency, intensity and importance of S and R and burnout on the LAPC's practice. From 6/1-12/31, 2017, a crossectional study using an anonymous/voluntary Online Survey was provided to active members of ALCP. We collected and analyzed data regarding demographics, role of S, R, and burnout. Results: 221/353 members from 20 Latin American Countries participated, RR:63%. Median age 47(SD+/-12), 75% were women. 40% Catholic. 58% were physicians, 19% nurses, 12% psychology, and other 12%. The median time of working in PC was 9 years (+/-7). LAPC considered themselves spiritual(median:8/10, range 0-10) and religious (5, 0-10). LAPC considered S/R very important in their lives (9/10, 0-10 and 6/10, 0-10), respectively. LAPC reported that S/R was a source of strength/comfort (9/10, SD+/-2), helped them to cope with their problems (8/10,+/-3), and helped them to keep their quality of life in a stressful work environment (8/10,+/-4). 60% LAPC felt energized and 86% reported not feeling exhausted after taking care of patients who are dying. This is associated with being spiritual (p=0.003) and its importance in life (p=0.025). 86% reported strongly/somewhat agreed with: "I feel called to take care of patients who are dying", this was associated with being spiritual (p=0.044). 31/221(14%) reported being burned out. No significant difference among gender, profession, age, years in PC, or importance of S/R. Having higher (34%) versus not (11%) experience emotional exhaustion after caring of the dying were more likely to report burnout (p

Background: Understanding family caregivers’ decisional role preferences is important for communication, quality of care, and patient and family satisfaction. The family caregiver has an important role in a patient’s decisional role preferences. There are limited studies on family caregivers’ preferences of the patient’s decision control at the end of life among Hispanics. Aims: To identify Hispanic caregivers’ preferences of the decision control of patients with advanced cancer and to compare the preferences of caregivers in Hispanic Latin American and Hispanic American caregivers. Design: We surveyed patients and their family caregivers referred to outpatient palliative care clinics in the United States, Chile, Argentina, and Guatemala. Caregiver preferences of patient’s decision control were evaluated using the Control Preference Scale. Caregivers’ and patients’ sociodemographic variables, patient performance status, and Hispanic American patient acculturation level were also collected. Participants: A total of 387 caregivers were surveyed: 100 (26%) in Chile, 99 (26%) in Argentina, 97 (25%) in Guatemala, and 91 (24%) in the United States. The median age was 56 years, and 59% were female. Results: Caregiver preference of patient’s decision control was passive, shared, and active for 10 (11%), 45 (52%), and 32 (37%) Hispanic American caregivers and 54 (19%), 178 (62%), and 55 (19%) Hispanic Latin American caregivers ( p = 0.0023), respectively. Caregiver acculturation level did not affect the preferences of the Hispanic American sample ( p = 0.60). Conclusions: Most Hispanic family caregivers preferred the patient to make shared decisions. Hispanic Latin American caregivers more frequently preferred patients to assume a passive decisional role. Acculturation did not influence the preferences of Hispanic American caregivers.

Spirituality, religiosity, and spiritual pain may affect advanced cancer patients' symptom expression, coping strategies, and quality of life.To examine the prevalence and intensity of spirituality, religiosity, and spiritual pain, and how spiritual pain was associated with symptom expression, coping, and spiritual quality of life.We interviewed 100 advanced cancer patients at the M.D. Anderson palliative care outpatient clinic in Houston, TX. Self-rated spirituality, religiosity, and spiritual pain were assessed using numeric rating scales (0=lowest, 10=highest). Patients also completed validated questionnaires assessing symptoms (Edmonton Symptom Assessment Scale [ESAS] and Hospital Anxiety and Depression Scale), coping (Brief COPE and Brief R-COPE), the value attributed by the patient to spirituality/religiosity in coping with cancer (Systems of Belief Inventory-15R), and spiritual quality of life (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-Expanded [FACIT-Sp-Ex]).The median age was 53 years (range 21-85) and 88% were Christians. Almost all patients considered themselves spiritual (98%) and religious (98%), with a median intensity of 9 (interquartile range 7-10) of 10 and 9 (range 5-10) of 10, respectively. Spiritual pain was reported in 40 (44%) of 91 patients, with a median score of 3 (1-6) among those with spiritual pain. Spiritual pain was significantly associated with lower self-perceived religiosity (7 vs. 10, P=0.002) and spiritual quality of life (FACIT-Sp-Ex 68 vs. 81, P=0.001). Patients with spiritual pain reported that it contributed adversely to their physical/emotional symptoms (P0.001). There was a trend toward increased depression, anxiety, anorexia, and drowsiness, as measured by the ESAS, among patients with spiritual pain (P0.05), although this was not significant after Bonferroni correction.A vast majority of advanced cancer patients receiving palliative care considered themselves spiritual and religious. Spiritual pain was common and was associated with lower self-perceived religiosity and spiritual quality of life.

BACKGROUND: Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit. METHODS: A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis. RESULTS: Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P ≤ .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P ≤ .0001). CONCLUSIONS: DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions. Cancer 2010. © 2010 American Cancer Society.

190 Background: Complementary and integrative health services are increasingly available to patients at cancer centers to help address physical and psychological needs. We review inclusion of spiritual pain (SP) as part of patient reported outcome (PRO) assessments in patients presenting for an outpatient integrative medicine consultation at a comprehensive cancer center. Methods: PRO data were collected as part of outpatient physician consultations at an integrative medicine clinic; we reviewed data between January 2013 and April 2017. Patients completed the Edmonton Symptom Assessment Scale (ESAS-FS, 12 symptoms, scale 0-10, 10 worst possible) immediately prior to the clinical encounter. ESAS distress subscales analyzed included psychological, physical, and global. Statistical analyses included summary statistics, two sample t-tests, correlations, and logistic regression. Results: We analyzed data from 4348 unique participants. Demographics included 65% women, average age 55.5, 78% Caucasian, 72% married or with significant other, majority Christian non-Catholic (49%) followed by non-specified (23%), and Catholic (20%). Overall, 41% of patients reported SP at baseline. Patients reporting a SP score of ≥ 1 (n = 1549) reported significantly higher levels of global, physical, and psychological distress than patients with SP scores of 0 (n = 2275) (all p’s < 0.001). Older patients and men were less likely to report SP. SP clustered with psychological symptoms of depression and anxiety (reliability coefficient 0.76). Conclusions: A significant number of cancer patients presenting for integrative medicine consultations reported having SP, with SP clustering with psychological versus physical symptoms. More research is needed to better understand how routine screening for SP contributes to assessments of overall psychological health.

180 Background: Caregivers of cancer patients often face significant physical, social, and emotional distress. There has been limited research on the association between Latino Caregivers’ spirituality/religiosity, meaning, and spiritual pain. Methods: We interviewed 336 Latino Caregivers of patients at Palliative Care clinics in Chile, Guatemala, and the US. Five open-ended questions were asked about spirituality, religion, meaning, and spiritual pain. Answers were transcribed and data analyzed. The analytic framework was based on an interpretive phenomenological analysis. Initial themes were grouped into themes, connections between themes were developed until a thematic rationale was achieved. Results: Latino caregivers’spirituality and religious beliefs were described as an anchor during the painful witnessing of a loved-ones’suffering. Main themes emerged about relationships, inner strength, hope, and acceptance/reconciliation. It was reported as an integrative force to help them to cultivate hope and love walking through their love one’s illness and their journey as caregivers. They expressed meaning as a manifestation of spirituality together with their love to others(spouse, family, others). The presence of Spiritual Pain was common and manifested as suffering and potential loss of loved ones, and broken relationship with Higher Power, that triggered a profound experience of their own pain(both spiritual and emotional) and their own quality of life. This was expressed in physical terms such as “heartache” and “soul ache.” Through discernment, prayer, and relationships with loved-ones, spirituality was integrated as a healing force during the caregiver journey. Spirituality was reported as a substance of hope weaved into an integrative process, as caregivers reconciled the tension of faith with sorrow. Conclusions: Spirituality and religious beliefs are reported as fundamental for Latino Caregivers. Despite these elements, Spiritual Pain is common and affects all aspects of their humanity. Most of them experienced a reconciliation experience with the broken relationships with themselves, with others or with Higher Power.

Mood disorders are among the most distressing psychiatric conditions experienced by patients with advanced cancer; however, studies have not shown a direct association of physical symptoms with depression and anxiety. The purpose of this study is to determine the relationship between the frequency and intensity of patients’ physical symptoms and their expressions of depression and anxiety. We retrospectively reviewed the records of 216 patients who had participated in three previous clinical trials conducted by our group. We assessed patients’ demographic data using descriptive statistics. We analyzed physical symptom frequency and intensity using the Edmonton Symptom Assessment System (ESAS) and anxiety and depression using the respective subscales of the Hospital Anxiety and Depression Scale (HADS-A and HADS-D). Sixty-two percent were male; the median age was 59 years (range 20–91 years). Seventy nine (37%) of the patients had depressive mood (HADS-D ≥ 8), and 94 (44%) had anxiety (HADS-A ≥ 8). Patients with depressive mood expressed higher frequency of drowsiness (68/78, 64%; p = 0.0002), nausea (52/79, 66%; p = 0.0003), pain (74/79, 94%; p = 0.0101), dyspnea (68/79, 86%; p = 0.0196), worse appetite (72/79, 91%; p = 0.0051), and worse well-being (78/79, 99%; p = 0.0014) and expressed higher intensity of symptoms (ESAS ≥ 1) [median (Q1–Q3)] including drowsiness [4 (3–7), p = 0.0174], fatigue [7 (5–8), p

Patients with advanced cancer may be referred for a palliative care consultation (PC) from a hospital emergency center (EC) or as inpatients. However, research about symptoms and outcomes in patients with advanced cancer who receive PC at the EC is limited. We reviewed demographic variables, frequency and intensity of symptoms (using the Edmonton Symptom Assessment Scale (ESAS)), PC interventions, time from admission to PC consultation, hospitalization duration, and discharge destination of 200 advanced cancer patients referred to PC services from the EC (“EC patients”) and 200 matched advanced cancer inpatients referred to PC services (“inpatients”) from January 1, 2010, through December 31, 2011. The median age for all patients was 56 years (range, 48–64 years); 222 (56 %) patients were female, and 243 (61 %) were white. There were no significant demographic differences between the EC patients and inpatients. The median time from admission to PC was 12 h (range, 7–23 h) for the EC patients and 24 h (24–96 h) for the inpatients (p

Background. Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency,characteristics,andoutcomesofdeliriuminpatients with advanced canceradmitted to an APCU. Methods. Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients’ demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score $7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management. Results. Of556patientsintheAPCU,323(58%)hadadiagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admissionand94(29%)developeddeliriumafteradmissionto the APCU.Delirium reversedin 85 of 323episodes (26%). Half of patients with delirium (n 5 162) died. Patients with the diagnosisofdeliriumhada lowermedianoverallsurvival than thosewithoutdelirium.Patientswhodevelopeddeliriumafter admission to the APCU had poorer survival (p # .0001) and alowerrateofdeliriumreversal(p5.03)comparedwiththose admitted with delirium. Conclusion. More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one-third of cases. Diagnosis of delirium was associated with poorer survival.The Oncologist 2015;20:1425–1431 ImplicationsforPractice:Deliriumisthemostcommonneuropsychiatricconditioninpatientswithseveremedicalillnessandthose at the end of life. It can be a source of distress for patients, their families, and the medical team.When missed, or if symptoms are misinterpreted, delirium may also lead to unnecessary interventions.This underlines the importance of diagnosis and detection of deliriumin populationsthatare atincreasedrisk.This study hasimportantimplications inpractice,asitcan assistclinicians inmaking decisions regarding other medical interventions, advance care planning, and communicating with families relating to end-of-life issues.

Purpose We examined the frequency and severity of financial distress (FD) and its association with quality of life (QOL) and symptoms among patients with advanced cancer in France. Design In this cross-sectional study, 143 patients with advanced cancer were enrolled. QOL was assessed using the Functional Assessment of Cancer General (FACT-G) and symptoms assessed using Edmonton Assessment System (ESAS) and Hospital Anxiety and Depression Scale (HADS). FD was assessed using a self-rated numeric scale from 0 to 10. Results Seventy-three (51%) patients reported having FD. Patients reported having FD were most likely to be younger (53.8 (16,7SD) versus 62 (10.5SD), p

Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable.To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs).We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED.Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99).Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed.

213 Background: Delirium occurs in about 45-60% hospitalized patients and 80-85% at the end of life. Predisposing factors include anti-cholinergic medications as is often cited in the geriatric literature. Our study aimed to demonstrate the association of anti-cholinergic burden and delirium in patients with advanced cancer. Methods: Retrospective review of 775 consecutive patients seen by the palliative care inpatient consult team. Demographic data, MDAS, ECOG, and anti-cholinergic drugs were determined. Anticholinergic burden was measured using the anticholinergic drug scale (ADS), anticholinergic risk scale (ARS), and anticholinergic burden scale (ACB). Patients with delirium and those who did not develop delirium were compared. Association between delirium and anticholinergic use were analyzed using Chi-squared test, univariate and multivariate logistic regression models. Results: 270/775 (35%) had delirium at the time of consult. Median age was 58 years. The median total of anticholinergic drugs in both groups was 6. Anticholinergic burden using the ADS (median 2 vs. 3; p = 0.09) and ARS (median 0 vs. 1; p = 0.75) was not different in both groups. ACB score were significantly different in both groups (median 1 vs 2; p = 0.0006). Univariate analysis showed hematologic malignancy (OR = 1.85, 95%CI: (1.23, 2.77), p 0.0030, poor ECOG, age (OR = 1.03, 95%CI: (1.02, 1.04), p < 0.0001) and ACB score (OR = 1.11, 95%CI: (1.03, 1.21), p 0.0069 to be associated with delirium. In our multivariate model ECOG (OR = 0.25, 95% CI: (0.17, 0.36), p < 0.0001), and age (OR = 1.03, 95% CI: (1.01, 1.04), p < 0.0001) are the only independent covariates significantly associated with the presence of delirium at admission. Conclusions: Our study found that in this younger population with cancer, the total number of anticholinergic drugs and the anticholinergic burden using 3 different scales were not associated with delirium suggesting a different mechanism. Further studies are needed to confirm these findings.

248 Background: Although cancer patients frequently use CAM, it is uncertain how oncologists’ spirituality and religiosity impact their decisions to use or recommend CAM with their patients. Methods: A US probability sample of 1,000 ASCO members was contacted by mail and email to complete a survey regarding clinical approaches to herb and supplement (HS) use by cancer patients. Results: Of 927 deliverable surveys, 423 surveys were returned for a response rate of 46%. Respondents were mostly men (72%), Caucasian (76%), with a median age of 48. Approximately 16% reported no religion, 19% Jewish, 24% Catholic, 28% Christian, and 13% other religions. Eighteen percent reported attending religious services at least once a week including 15% who attend several times per week. Twenty-eight percent reported high theological pluralism (skepticism regarding whether one religion is the only true religion). Fifty-eight percent self-described themselves as very or moderately spiritual. Univariate analyses indicated significant correlations with self-reported spirituality and religious service attendance and the likelihood of personal CAM use, recommending any CAM, and recommending HS. In multivariate analyses, predictors of personal CAM use were: female gender (OR = 5.6, CI 0.09-0.37), non-Caucasian (OR = 3.0, CI 0.16-0.70), educated in HS (OR = 2.6, CI 1.37-5.08), attending religious services less than monthly (OR = 3.0, CI 0.17-0.65), and self –reported high or moderate spirituality (OR = 3.2, CI 1.5-6.6). Physician predictors for sometimes or often recommending HS were male gender (OR = 1.85, CI 0.92-3.75) and self–reported low spirituality (OR = 2.9, CI, 0.15-0.77). Recommending CAM was associated with female gender (OR = 2.6, CI 0.15-0.97), educated in HS (OR = 3.4, CI 1.46-7.78), and self–reported high or moderate spirituality (OR = 2.8, CI 1.26-6.31). No correlations were found with religious affiliation. Conclusions: This is the first study to identify self-reported spirituality as a significant factor among US oncologists’ decision to use CAM and recommend CAM to patients, and further studies are needed to explore this potential influence.

Sleep disturbance (SD) is a significant source of distress for patients with cancer. Studies of patients with advanced cancer receiving palliative care to identify symptoms associated with the severity of SD are limited.In this study, we sought to identify the symptoms measured by the Edmonton Symptom Assessment Scale (ESAS) that are associated with SD, as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary aims of the study were to determine the association between occurrences of SD with occurrences of other symptoms and screening performance of the ESAS-Sleep item against the PSQI.We reviewed the completed ESAS and PSQI assessments of 101 patients with advanced cancer who were receiving palliative care and had been admitted to prospective clinical trials previously initiated by us. Patients with a PSQI score of ≥ 5 were considered to have an SD. The frequency and severity of the ESAS symptoms items, their correlation with each other, the PSQI score, and the screening performance of the ESAS-Sleep item were calculated.The median age of patients was 60 years. Most were white non-Hispanic (73%), had lung or breast cancer (41%), and were diagnosed with SD (85%). The PSQI score was correlated with the ESAS items of pain (r=0.27, P=0.006), dyspnea (r=0.25, P0.001), well-being (r=0.35, P0.0001), and sleep (r=0.44, P0.0001). Compared with patients without SD, those with SD were more likely to report pain (P=0.0132), depression (P=0.019), anxiety (P=0.01), and a poorer sense of well-being (P=0.035). An ESAS-Sleep item cutoff score of ≥ 3 (of 10) resulted in a sensitivity of 74% and a specificity of 73%.SD is associated with increased frequency of pain, depression, anxiety, and a worse sense of well-being. These four symptoms should be assessed in all patients with advanced cancer with a complaint of SD. The ideal cutoff point of the ESAS-Sleep item for screening for SD is a score of ≥ 3. More research is needed to better characterize this frequent and distressing syndrome.

BACKGROUND: The symptom burden of intensive care unit (ICU) patients who are referred to a palliative care team (PCT) has not been characterized to the authors' knowledge, and the response of these symptoms to the palliative care intervention has not been reported. METHODS: The authors retrospectively reviewed PCT consults for ICU patients who were seen between July 2006 and October 2007. To characterize symptom distress and outcomes in ICU patients who were referred to PCT in a cancer center, information and descriptive statistics about patients' demographics, comorbidities, PCT findings, interventions, and outcomes were obtained. The chi-square test was used to analyze ICU and PCT mortality, and the signed-rank test was used to analyze PCT interventions. RESULTS: Of 1637 PCT consults, 88 consults (5%) were from the ICU. The median patient age was 60 years (range, 22-87 years), and 41 patients (46%) were women. The types of cancers were hematologic (19 patients; 22%), gastrointestinal (19 patients; 22%), lung (18 patients; 20%), and others (24 patients; 26%). Nineteen patients were on mechanical ventilation (MV), and 24 patients were on bilevel positive airway pressure (BIPAP). The findings were delirium (71 patients; 81%), dyspnea (67 patients; 76%), pain (74patients; 84%), fatigue (84 patients; 95%), and anxiety (57 patients; 65%). The interventions used were opioid management (99%), steroids (70%), antipsychotics (76%), and counseling (100%), do not resuscitate conversion (62 of 88 patients; 70%), withdrawal of MV (15 of 19 patients; 79%), and withdrawal of BIPAP (26 of 26 patients; 100%). Improvement was reported in pain (67 patients; 90%), dyspnea (60 patients; 90%), anxiety (51 patients; 80%), and delirium (31 patients; 44%). Thirty-five patients (40%) were transferred to the palliative care unit (PCU). Fifty-one ICU/PCT patients (58%) died during admission versus 130 of 1549 (8%) non-ICU PCT patients (P < .0001). Twenty-three of 35 patients who were transferred to the PCU (66%) died there versus 212 of 629 patients (34%) who were admitted to the PCU from another service (P < .0001). Thirty-seven of 88 ICU/PCT patients (42%) were discharged alive. CONCLUSIONS: ICU patients who are referred to the PCT have severe symptom distress. The PCT was able to identify multiple problems and make numerous pharmacologic and nonpharmacologic recommendations that improved these symptoms, including the participation in do not resuscitate conversion and withdrawal of MV and BIPAP. Although many patients in this population died, a significant subset, including those who were transferred to the PCU, survived to discharge. Cancer 2009. © 2009 American Cancer Society.

Alcoholism is a devastating disease that can cause patient and family suffering and is frequently underdiagnosed. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE questionnaire is a widely used tool for alcoholism screening. The purpose of this study was to determine the frequency and characteristics of patients who screen positive for alcoholism in a palliative care outpatient clinic (PCOC).We reviewed 665 consecutive charts of patients referred to the PCOC and collected data regarding age, gender, and type of cancer. For the first 100 consecutive CAGE positive (CAGE+) and 100 consecutive CAGE negative (CAGE-) patients, time from advanced cancer diagnosis (AC) to PCOC was calculated, and symptoms (Edmonton Symptom Assessment Scale, ESAS) and Morphine Equivalent Daily Dose (MEDD) were collected.CAGE was available for 598 of 665 (90%) patients. Of 598 patients, 100 (17%) were CAGE+. CAGE+ patients were younger (58 versus 60 years, p0.05), predominantly male (68% versus 47%, p0.0001), and with head/neck malignancies (24% versus 9%, p0.05). CAGE+ patients were referred earlier (5 +/- 27 months after AC, p0.0001). At baseline, pain, sleep, dyspnea, well-being, and total symptom distress were significantly worse among CAGE+ patients. Both groups showed similar improvement in symptoms. CAGE+ patients were more frequently on opioids upon referral (47/100 versus 29/100, p0.05) and follow-up (27/65 versus 16/68, p0.05). At follow-up, opioid doses did not show significant changes.Seventeen percent of the patients were CAGE+. These patients were referred earlier to palliative care, had more symptom expression, and were more frequently on opioids. The palliative care team successfully improved symptom control in both groups without opioid dose escalation.

Predicting inpatient mortality has clinical and financial implications and helps improve the care of patients with advanced cancer and their families. Models with excellent validity and reliability are available for mortality prediction in intensive care units. The purpose of the current study was to determine factors associated with increased likelihood of mortality in an acute palliative care unit (APCU). We retrospectively reviewed the medical records of 500 patients admitted to the APCU. Basic characteristics and information on symptom intensity, vital signs, relevant laboratory tests, and the presence or absence of delirium were obtained from the records of the consultation that preceded the APCU admission. Univariate and multivariate analyses were conducted to compare characteristics of patients who died in the APCU with characteristics of those who were discharged alive. Of the 500 patients admitted to the APCU, 124 (25%) died. Factors that were jointly prognostic for death, using multivariate analysis were younger age (odds ratio [OR] for older patients [≥65] 0.43, 95% confidence interval [CI], 0.25−0.73, p

Delirium is considered to be multifactorial, especially in elderly patients and those with advanced cancer, and can cause significant distress. High baseline vulnerability at the end of life, combined with cachexia, hepatic impairment, general comorbidities, and impaired functional status, can make delirium difficult to correct. Nonetheless, approximately 50% of delirium episodes are potentially reversible and reversible causes should be investigated. Hypercalcemia is one of the reversible metabolic causes of delirium in patients with advanced cancer. Here, we present the case of a patient with metastatic small cell prostate carcinoma who presented to our palliative care clinic with uncontrolled symptoms. A thorough evaluation using appropriate assessment tools revealed that he had delirium, and hypercalcemia was found to be the major etiologic factor. An interdisciplinary team approach (including a nutritionist, pharmacist, counselor, social worker, chaplain, and case manager) was provided. With aggressive symptom management and correction of hypercalcemia and other reversible causes of delirium, the delirium was resolved and the symptoms were controlled. This case illustrates the importance of screening for delirium in patients with severe symptom distress and how the interdisciplinary management of reversible causes of delirium, including hypercalcemia, can improve patients' symptoms and quality of life.

247 Background: Dyspnea is very complex and distressing symptom in patients with advanced cancer. The therapeutic goal of its symptomatic management is to relieve the patient’s breathlessness sensation. Limited literature has addressed the characteristics and clinical outcomes of advanced cancer patients with severe dyspnea receiving HFO admitted to PCU. Methods: We reviewed the records of 101 advanced cancer patients with dyspnea receiving HFO and 110 matched PCU inpatients with dyspnea receiving regular O2 flow (NoHFO) between January 1 to December 31, 2012. Demographics, frequency and intensity of symptoms at PCU admission and follow-up, and outcomes were recorded. Results: Median age: 60 years, range (51, 69). 56% were Male. White(71%), Hispanic(13%), African American(10%), Asian (4%). Primary cancer: Lung (27%), Gastrointestinal (19%), Hematological (18%), Breast (13%), Gynecological (6%). Dyspnea was present in all cases and it was related mainly to: lung involvement by cancer (53%), pneumonia (40%), Congestive Heart Failure (6%), COPD (8%). ECOG: 4. No significant difference in age, ethnicity and type of cancer, ECOG, and possible cause of dyspnea among both groups. HFO and NoHFO were started the same day of admission. Median ESAS symptoms (Interquartile range: IQR) for HFO was Pain 4.5 (2, 7) vs. 5 (3, 7) for NoHFO, p = 0.1423; fatigue [7(5, 8) vs. 7 (5, 8), p = 0.450]; depression [3 (1, 5) vs. 3.5 (2, 5), p = 0.81]; anxiety 7 (4, 9) vs. 6 (3, 8), p = 0.01; dyspnea [7.5( 6, 9) vs. 5 (3, 8), p < 0.0001]. Memorial Delirium Scale 5 (2, 15) vs. 7(2, 15), p = 0.77). Morphine Equivalent Daily Dose: 48 (36, 120) vs. 55 (30, 120), p = 0.72. The median difference among first and follow up ESAS was Pain 0 (-3, 1) vs. -1(-2, 1), p = 0.62; fatigue[(-2, 1) vs. 0 (-2, 0), p = 0.63]; depression [0 (-1, 1) vs. 0 (-1, 2), p = 0.93]; anxiety [0 (-2, 2) vs. 0 (-2, 2), p = 0.94; dyspnea [0( -1, 1) vs. -1 (-2, 1), p = 0.18]. Memorial Delirium Scale 0 (-1.5, 5.5) vs. 0 (-2, 3), p = 0.21).The median time (IQR) from HFO started to discharge was 10 days (6, 15) vs. 8.5 (5, 14) days for NoHFO, p = 0.07). The median time(IQR) from HFO started to Death was 10.5 (7, 19) vs. 13.5 (7, 26) days for NoHFO, p = 0.18. 77/101(76%) HFO patients vs. 56/110 (51%) NoHFO died at the hospital, p = 0.002. 24/101(23%) HFO patients were discharged alive weaned off HFO. The Odd ratio for hospital death in patients with HFO vs. NoHFO was 4.83 (95% CI: 1.72 – 13.59), p = 0.003. Conclusions: Severe dyspnea is significant at the end of life of advanced cancer patients. Patients with HFO require similar MEDD than NoHFO patients. Inpatient mortality is higher in patients with HFO. More research is needed.

208 Background: AdCa experience severe physical, psychosocial and existential distress. Their needs might not be met only by standard care. We compared outcomes of AdCa receiving SPC at a General Public Hospital (GPH) and at a Comprehensive Cancer Center (CCC). Methods: We reviewed 364 consecutive AdCa(182 at GPH and 182 at CCC). AdCa were managed by SPC-specialists with common clinical-pathways. We assessed symptoms(Edmonton Symptom Assessment System:ESAS) and outcomes at consult and first follow-up. Results: Race was White, African-American, and Hispanic in 42(23%), 70(39%), 63(35%) at GPH vs. 112(64%, p

140 Background: Admissions to ED are considered undesirable for AdCa receiving palliative care. There is limited research about clinical characteristics of AdCa followed by SCPC who visited ED, and if these ED visits can be categorized as avoidable or unavoidable. Methods: Retrospective study of 200 consecutive AdCa evaluated by the SCPC physician who visited ED between January 2010 and December 2011. All patients were instructed to call to our main number if any change in symptoms. Based on pre-defined criteria AdCa were classified as having an avoidable (if the problem could have been managed at the outpatient center or by telephone) or unavoidable visit. Demographics and clinical characteristics were collected and analyzed. Results: 47/200 (23.5%) AdCa had avoidable ED-visits (AvED) and 153/200 (76.5%) had unavoidable ED-visits (NAvED). Main reasons for NAvED: changes in mental statu s(24/153, 16%), infectious processes (32/153, 21%), new onset/worsening of pain and dyspnea (75/153,49%), and severe worsening others symptoms (22/153,14%). Age, gender, marital status, and cancer types, reasons for referral to SCPC, and time to ED-visit after SCPC visit were not significantly different between AvED and NAvED patients. Baseline Edmonton Symptom Assessment Scale showed no significant difference in pain, dyspnea, fatigue, drowsiness, nausea, well-being, anxiety, and depression for AvED vs. NAvED; except for sleep ≥1: 141/153 (92%) vs. 37/47 (79%), p=0.01001, respectively. None of the patients phoned the SCPC before to ED visit. 17/153 (11%) of AdCa called their primary oncology before NAvED visit vs. 1/46(2%) call before AvED, p=0.078. Multivariate analysis showed that NAvED was associated with worsening of pain (OR:2.485, p

9002 Background: Cancer-related-fatigue (CRF) is the most common and distressing symptoms in patients with advanced cancer. Currently, there is no standard treatment for CRF. Although corticosteroids have been used in the treatment of CRF, there are no well-powered placebo-controlled trials that used a validated CRF outcome measure. The primary objective of this prospective, randomized, double-blind, placebo-controlled study is to compare the effect of DM versus placebo on CRF. Methods: Advanced cancer patients with fatigue ≥ 4/10 on the Edmonton Symptom Assessment Scale (ESAS) and at least 2 other CRF-related symptoms (pain, nausea, appetite, depression, anxiety or sleep disturbance ≥ 4/10), normal cognition, no infections and hemoglobin ≥ 9 g/L were eligible for enrollment. Patients were randomized to either receive dexamethasone 4 mg orally twice a day for 15 days (primary end point) or matching placebo. The primary outcome was the day 15 change in Functional Assessment of Chronic Illness-Fatigue (FACIT-F) subscale scores. Differences in the group means (normal distribution) were analyzed using the two-sample t-test. Results: In 83 evaluable patients (43 DM and 40 placebo), median age was 60 years, 61% were white, and 53% were female. There was no difference in the demographics and fatigue (FACIT-F subscale) between DM and placebo groups except for sex (p=0.02). The mean (SD) FACIT-F subscores at baseline and at day 15 for DM were 18 (11) and 27 (11) (p

The Impact of Spirituality, Religiosity, and Spiritual Pain in Coping Strategies and Quality of Life (QOL) of Caregivers of Advanced Cancer Patients (CACP) in the Palliative Care (PC) Setting (717) Marvin Delgado-Guay, MD, University of Texas Medical School at Houston, Houston, TX. Henrique Parsons, MD, University of Texas MD Anderson Cancer Center, Houston, TX. David Hui, MD MSc FRCPC, University of Texas MD Anderson Cancer Center, Houston, TX. Maxine De La Cruz, MD, University of Texas MD Anderson Cancer Center, Houston, TX. Kathy Govan University of Texas MD Anderson Cancer Center, Houston, TX. Eduardo Bruera, MD, University of Texas MD Anderson Cancer Center, Houston, TX. Steve Thorney. (All speakers have disclosed no relevant financial relationships.)

9071 Background: S, R and SP may affect AdCa patients' symptom expression, coping strategies and quality of life. Limited research is available to define these concepts. In this prospective cross s...

9589 Background: Cardiopulmonary resuscitation (CPR) has limited benefit in advanced cancer patients (pts). Refusal of medically appropriate DNR (maDNR) may cause harm and distress for pts, families, and the medical team. We conducted a retrospective study to determine the frequency of refusals of maDNR in a tertiary PC unit in a comprehensive cancer center, and characterize the differences between maDNR acceptors (A) and refusers (R). Methods: We reviewed 2538 consecutive admissions to the PC unit to find refusals of maDNR. Data were collected regarding demographical/clinical factors, 0–10 Edmonton Symptom Assessment System, DNR, CPR, and death for the first 100 R and 200 A pts. Results: DNR was considered medically appropriate for 2530/2538 (99%) admissions. 2374/2530 admissions were of unique pts, and 100/2374 (4%) refused maDNR. 3/3 (100%) R pts who coded underwent CPR versus 0/87 A pts who coded (0%, p No significant financial relationships to disclose.

9543 Background: Alcoholism is frequently underdiagnosed in cancer patients. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE...

20756 Background: Predicting inpatient mortality has clinical and financial implications and helps improve the care of advanced cancer patients and their families. Models are available for mortalit...

20520 Background: A significant proportion of cancer deaths occur in the in ICU. Advanced cancer patients (pts) admitted to ICU and their family member experience severe distress. The impact of PCT in the ICU pts is not known. Purpose: To characterize symptom distress and outcomes in ICU pts referred to a PCT in a cancer center. Methods: A retrospective review of the PCT consults was done in pts admitted to ICU between 07/2006 and 10/2007. Demographic data, comorbidities, PCT findings, interventions, and outcomes were collected. Results: 88 ICU pts seen among 1637 PCT consults (5%). Median age (range) was 60 years (22–87), 46% female. Primary was hematological (22%), gastrointestinal (22%), lung (20%), breast (9%), and others (26%). 76% had metastatic disease and 44% had chemotherapy ≤4 weeks prior evaluation. 19 pts (21%) were on mechanical ventilation (MV) and 24 pts (27%) on BIPAP. Findings: delirium (81%), dyspnea (82%), pain (84%), fatigue (95%), anxiety (65%), sedation (78%), depression (45%), insom...

e20612 Background: Supportive Care Outpatient Clinics (SCOC) offer comprehensive care and symptom management to patients with advanced cancer (AdCa). Missed appointments (MA) are frequent but they are no studies on the clinical outcomes of patients who fail to show for consultation. Methods: We determined the frequency of MA, including clinical and demographic data, and reviewed clinic appointment records for 218 consecutive kept (KA) and 218 MA for distinct patients referred to SCOC from January to December 2011. Results: 218/1,352 (16%) AdCa who were referred to our SCOC, missed their appointment. The median age was 57 years (interquartile range 49-67). The mean (range) time between referral and appointment was 7.4 days (0-71) for KA vs. 9.1 days (0-89) for MA (p=0.0062). Age, gender, marital status, and cancer types or stages, and reasons for referral to SCOC were not significantly different between MA and KA patients. African Americans had more MA 49/218 (22%) vs. 31/217 (14%), p=0.06. The reasons for MA were: admission to the hospital 17/218 (8%), death 4/218 (2%), appointment with primary oncologist 37/218 (18%), other appointments 19/218 (9%), visits to emergency room(ER) 9/218(9%), and unknown 111/218(54%). MA patients visited more the ER at 2 weeks 16/214 (7%) vs. 5/217 (2%), p=0.01, and 4 weeks 17/205(8%) vs. 8/217(4%), p=0.06. Median survival for MA patients was 177 days (range:127-215) vs. 253 days (range:192-347) for KA patients (p=0.013). Multivariate analysis showed that MA were associated to the time between referral and scheduled appointment (OR: 1.026/day, p=0.03), referral from targeted therapy services (OR:2.177, p=0.004), living at Texas/Louisiana regions (OR;2.345, p=0.002), having advanced directives (OR:0.154, P