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Title: Factors associated with the aggressiveness of care at the end of life for patients with cancer dying in hospital: a nationwide retrospective cohort study in mainland Portugal
Authors: Martins-Branco, Diogo
Lopes, Silvia
Canario, Rita
Freire, Joao
Feio, Madalena 
Ferraz-Goncalves, Jose
Sousa, Gabriela 
Lunet, Nuno
Gomes, Bárbara 
Keywords: hospital mortality; neoplasms; palliative care; risk factors; terminal care
Issue Date: Nov-2020
Publisher: Elsevier
Project: Calouste Gulbenkian Foundation as part of the DINAMO Project (grant number 127 988 to BG) 
Núcleo Regional do Sul – Liga Portuguesa Contra o Cancro (43/2015 and 35/2016 to DM-B) 
Serial title, monograph or event: ESMO Open
Volume: 5
Issue: 6
Abstract: Introduction There is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL), defined as overly aggressive treatments that compromise the quality of life at its end. Recognising the most affected patients is a cornerstone to improve oncology care. Our aim is to identify factors associated with ACCEoL for patients with cancer dying in hospitals. Methods All adult patients with cancer who died in public hospitals in mainland Portugal (January 2010 to December 2015), identified from the hospital morbidity database. This database provided individual clinical and demographic data. We obtained hospital and region-level variables from a survey and National Statistics. The primary outcome is a composite ACCEoL measure of 16 indicators. We used multilevel random effects logistic regression modelling (p<0·05). Results We included 92 155 patients: median age 73 years; 62% male; 53% with metastatic disease. ACCEoL prevalence was 71% (95% CI 70% to 71%). The most prevalent indicators were >14 days in the hospital (43%, 42–43) and surgery (28%, 28–28) in the last 30 days. Older age (p<0·001), breast cancer (OR 0·83; 95% CI 0·76 to 0·91), and metastatic disease (0·54; 95% CI 0·50 to 0·58) were negatively associated with ACCEoL. In contrast, higher Deyo-Charlson Comorbidity Index (p<0·001), gastrointestinal and haematological malignancies (p<0·001), and death at cancer centre (1·31; 95% CI 1·01 to 1·72) or hospital with medical oncology department (1·29; 95% CI 1·02 to 1·63) were positively associated with ACCEoL. There was no association between hospital palliative care services at the hospital of death and ACCEoL. Conclusion Clinical factors related to a better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and gastrointestinal malignancies might represent groups with complex needs, and haematological patients may be at increased risk because of unpredictable prognosis. Improvement of hospital palliative care services could help reduce ACCEoL, particularly in cancer centres and hospitals with medical oncology department, as those services are usually under-resourced, thus reaching few.
ISSN: 20597029
DOI: 10.1136/esmoopen-2020-000953
Rights: openAccess
Appears in Collections:FMUC Medicina - Artigos em Revistas Internacionais

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