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

Abstract

AbstractBackgroundStudies 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.MethodsUsing 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.ResultsOf 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).ConclusionsContrary 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.