Aggressive End-of-Life Care Across Gradients of Cognitive Impairment in Nursing Home Patients with Metastatic Cancer

Authors

Siran M. Koroukian, Case Western Reserve UniversityFollow
Sara L. Douglas, Case Western Reserve UniversityFollow
Long Vu, Case Western Reserve UniversityFollow
Hannah L. Fein, Case Western Reserve University
Nicholas K. Schiltz, Case Western Reserve UniversityFollow
Jennifer Cullen, Case Western Reserve UniversityFollow
Cynthia Owusu, Case Western Reserve UniversityFollow
Martha Sajatovic, Case Western Reserve UniversityFollow
Johnie Rose, Case Western Reserve UniversityFollow

Author ORCID Identifier

Martha Sajatovic

Document Type

Article

Publication Date

7-28-2023

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

Language

english

Publication Title

Journal of the American Geriatrics Society

Rights

© The Author(s) 2024. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/), which permits non-commercial copying and redistribution of the material in any medium or format, provided the original work is not changed in any way and is properly cited.

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.

Recommended Citation

Koroukian SM, Douglas SL, Vu L, et al. Aggressive end-of-life care across gradients of cognitive impairment in nursing home patients with metastatic cancer. J Am Geriatr Soc. 2023;71(11):3546‐3553. doi:10.1111/jgs.18526