SHORT COMMUNICATION

Palliative care is a key component of daily practicein oncology: descriptive study of hospitalisationevents at an oncology treatment centre

Enrique Espinosa & Álvaro Pinto & Pilar Zamora &

Jaime Feliu & Beatriz Martínez &

Manuel González Barón

Received: 1 December 2009 /Accepted: 29 April 2010 /Published online: 28 May 2010# Springer-Verlag 2010

AbstractPurpose The impact that palliative care services have hadon admission to oncology services has not been well-defined. This retrospective study was undertaken in theoncology service of a general hospital where there is also apalliative care service.Methods The medical records of 397 patients (542 events)admitted during a period of 6 months at a single centre werereviewed.Results The main final diagnoses were tumour progression,infection and chemotherapy administration. Seventeenpercent of patients died during hospitalisation. The decisionto withdraw active treatment was taken during this time in11% of patients.Conclusion Key therapeutic decisions are commonly madeduring hospitalisation events of patients with cancer. Ourresults suggest that oncologists still take care of patients atthe end of life, although this may highly depend on modelsof health care and admission criteria.

Keywords Oncology service . Palliative care service .

Admission . Discharge . Outcome

Introduction

Palliative care for cancer patients has received increasingattention in the last decades. In a 1998 special article, the

American Society of Clinical Oncology described theoncologists' responsibility to care for their patients fromthe moment of diagnosis throughout the course of theillness [1]. Effective palliative control requires an interdis-ciplinary team that provides care in all patient settings.Many oncologists and primary care physicians are nowsupported by doctors with specific training in palliation, notonly in the community but also in hospitals.

Better symptom control could lead to decreased admis-sions to oncology services in patients with advanceddisease. However, very little information about admissionpatterns to oncology services has been published in recentyears. One might expect that the development of palliativecare services would (1) decrease the number of suchadmissions for symptomatic relief and (2) limit the role ofoncologists in treating hospitalised patients; but this has notbeen demonstrated. Search in PubMed using combinationsof the terms admission, inpatient, discharge, outcomes,oncology, oncology unit, oncology ward and descriptionyields only a handful of informative reports [2, 4, 7–11]. Inthe present study, we describe hospitalisation events in theoncology service of a general hospital that also has a unit ofacute palliative care. Our aim was to evaluate and classifythe main activities performed in our oncology ward.

Patients and methods

The medical reports of patients discharged in the oncologyservice of a single general hospital from January 2009 toJune 2009 were reviewed. The oncology service has 30beds for hospitalisation, with a median occupancy over90%. All cancer patients without a formal diagnosis ofterminal disease are admitted into this unit. Terminal

E. Espinosa (*) :Á. Pinto : P. Zamora : J. Feliu :B. Martínez :M. González BarónService of Oncology, Hospital La Paz,Paseo de la Castellana,261–28046 Madrid, Spaine-mail: eespinosa00@terra.es

Support Care Cancer (2010) 18:1231–1234DOI 10.1007/s00520-010-0903-0

patients can be admitted either to oncology or palliativecare services, but admissions to the latter require grant by adoctor from this service, whereas admissions to theoncology service can be directly made from the emergencyward. The present study did not include events related tothe palliative care service. Our hospital is a public generalhospital with 1,500 beds, supporting a population of600,000.

An event was defined as a single period of hospital-isation. Active treatment was defined as any specificanticancer drug or radiotherapy given with curative orpalliative intention to obtain a response of the disease, asopposed to symptomatic therapy. The following data wererecorded and tabulated: age, sex, type of primary tumour,diagnosis at the time of admission, main diagnosis at thetime of discharge, length of hospital stay and main therapyadministered (active or symptomatic) before, during andafter hospitalisation. Detailed drug therapy was notrecorded.

Results

Five hundred forty-two events corresponding to 397patients were recorded. Most patients had only onehospitalisation, but 85 had more than one event (20 ofthem were receiving repeated courses of chemotherapy, and65 had complications from either the tumour or its therapy).Sixty percent of the patients were male, and the median agewas 63 years (Table 1).

Lung carcinoma was the most common primary tumourin 22% of events, followed by colorectal cancer in 17%,soft tissue sarcomas in 12% and breast cancer in 10%. Mostevents in patients with sarcoma were related to theadministration of chemotherapy in continuous infusion.

Sixty-six percent of patients were under active treatmentwith some kind of chemotherapy by the time of admission.

Chemotherapy consisted of classical drugs, targeted thera-pies or, less commonly, immunotherapy. Radiotherapy wasthe main therapy in only 2% of patients. Twenty-onepercent of patients had not initiated active therapy (eitherchemo or radiotherapy), usually because of patient's refusalor because the chances of benefit from active therapy hadbeen estimated to be very low. Eleven percent of patientshad exhausted active treatment and were receiving justsupportive therapy.

The most common cause of admission was chemother-apy administration in 21% of events, followed by infectionin 14%, neurological impairment in 11%, dyspnoea in 10%and pain in 7%. Table 2 reflects the final main diagnosis:the leading diagnoses were tumour progression, infection(23% of cases each) and chemotherapy administration(21%).

Supportive therapy for symptomatic relief was the onlytherapy given in 67% of events. This usually includedanalgesia, hydration, antibiotics, antiemetics and cortico-steroids. Chemotherapy was also used in 27% andradiotherapy in 5%.

Cause of discharge was symptom improvement in 57%of events, end of the course of chemotherapy in 21%, deathin 17% and moving to a hospice in 5%. The median staywas 6 days (range, 1 to 74 days). At the time of discharge,53% of patients were expected to continue chemotherapy;3% should receive radiotherapy; 18% remained undersymptomatic therapy, and decision about withdrawal ofactive therapy was pending in 9%. The decision towithdraw active treatment was taken during the time ofhospitalisation in 11% of patients.

Discussion

In a recent special article, the American Society of ClinicalOncology recommended that palliative care services be

Number of events 542

Age Median 63 (19–96)

Sex Men/women 60/40%

Primary tumour Digestive (mainly colorectal) 28%

Lung 22%

Sarcoma 12%

Breast 10%

Urologicala 9%

Gynaecologicalb 5%

Otherc 13%

Previous therapy None or just surgery 21%

Chemotherapy 66%

Radiotherapy 2%

Symptomatic for palliation 11%

Table 1 Patients' characteristics

a Prostate in 1/3, urothelial in 1/3,kidney plus testicular in 1/3b Ovarian and peritoneal tumoursin 2/3 of thesec Brain, unknown origin, melano-ma, lymphoma and thyroid

1232 Support Care Cancer (2010) 18:1231–1234

available in cancer centres [5]. This involves integration ofsuch services into the routine care of cancer patients fromdiagnosis. As specific units for palliative care have beenestablished in many centres, some specialists may think thatthey should focus on anticancer treatment in outpatientfacilities and that attention to palliative issues is now lesscommonly required. Our results on admissions to theoncology service of a public general hospital indicate thecontrary.

Admission criteria to palliative care services are ex-tremely variable among institutions, reflecting differentmodels of health care [2, 7–9]. Although full integrationof oncology and palliative care services is desirable,separate functioning is commonly seen, which may resultin marked differences in treatment protocols for admissioncriteria. The model of insurance can also affect access topalliative care. For this reason, our results and conclusionsshould be drawn with caution because they may not befully applicable to other areas. In our country, for instance,there is free health coverage for the entire population inpublic hospitals. Even when palliative care services have

been present in the main populations for over a decade,many patients and their relatives still do not know aboutthem or feel reluctant to use these services. Also, we did nothave a control series before the palliative care service wasestablished, which could have showed changes along time.In one study, the opening of such a unit in a generalhospital led to a decrease in administrative endpointsrelated to palliative and end-of-life care in the oncologyward [9]. Even so, we think that our general conclusionsmay be valid for a number of different settings.

Lung and colorectal tumours were the most commonprimaries, as expected due to their prevalence in the cancerpopulation. Breast cancer accounted for only 10% of eventsin our series, probably because of the good prognosis ofmost women with this malignancy, and also because somethese patients are hospitalised in the gynaecology serviceand not in the oncology service.

Cause of admission is also very variable. At ourinstitution, patients usually receive chemotherapy in theoutpatient area, but, even so, treatment administrationaccounted for 21% of hospitalisation events. In anotherseries with 779 inpatients, 81% of them were receivingchemotherapy [10].

Infectious complications were the second cause ofadmission to our service, even when we only treat solidmalignancies (patients with lymphoma and leukaemiareceive treatment in the haematology service). Cancerassociated immunosupression and toxic neutropenia arestill important issues in the cancer population. On the otherhand, pain was the main cause for hospitalisation in 7% ofour patients, reflecting acceptable pain control rates. This isdue not only to the availability of new opioids, radiationtherapy, radionuclide isotopes or invasive techniques, butalso to the presence of a palliative care unit attendingpatients at home. Of course, many of our patients had somedegree of pain, but it was not the leading cause foradmission.

Twenty-three percent of patients had tumour progressiondetected during hospitalisation, a situation which usuallyleads to modify specific therapy for cancer. In 11% ofcases, the decision consisted of withdrawal of activetreatment. In a series of patients with lung cancer, 30%had progressive disease at the time of admission [2], andthis percentage rose to 50% in another series including avariety of primary tumours [11]. These figures, along withthe number of chemotherapy procedures, reveal the needfor oncologists in the inpatient ward. In some institutions,other specialists take care of hospitalised patients, withoncologists acting as consultants, but in all cases oncolo-gists must make key decisions.

On the other hand, appropriate management of cancercomplications and end-of-life issues require that oncologistshave specific training in palliation. The American Society

Table 2 Main diagnosis at the time of discharge

Tumour progression

All 23%

Brain progression 8%

Lung progression 6%

Liver progression 5%

Infection

All 23%

Pneumonia 8%

Febrile neutropenia 6%

Sepsis 3%

Chemotherapyadministration

21%

Chemotherapytoxicitya

Mucositis, oedema,vomiting, and diarrhoea

6%

General deterioration 4%

Thromboembolism 4%

Not related to canceror therapy

All 4%

Chronic bronchitis 2%

Other 2%

Intestinal obstruction 3%

Other Spinal compression, pleuraleffusion, oesophageal stricture,renal failure, digestivehaemorrhage, hydronephrosis,hypercalcemia, hyponatremia,pericarditis, and diagnosticprocedure

12%

aOther than febrile neutropenia

Support Care Cancer (2010) 18:1231–1234 1233

of Clinical Oncology recently stated that “… oncologistsneed more knowledge and skill to manage complex situationsand interactions” to provide care to patients with multiple,concurrent issues [5]. In our series, 17% of admitted patientsdied in hospital, which is in the range of other series ofpatients at units of oncology [10] or palliative care [4]. In ourgeographic area, there is a domiciliary palliative care unit,but, even so, 70% of cancer patients die in hospital(unpublished data). A British study indicated that, despitemore palliative care services, the proportion of people dyingat home had not increased over time [3]. This trendparticularly affects older people, as shown in anotherretrospective study [6]. As the hospital is still the mostcommon place of death for cancer patients, oncologists arelikely to be involved in their care until the end.

As a conclusion, key therapeutic decisions are common-ly made during hospitalisation events of patients withcancer. Our results suggest that oncologists may take careof patients at all stages of disease, even at the end of life,although this highly depends on the models of health careand admission criteria in different areas. The presence ofpalliative care services both in hospitals and in thecommunity does not modify the fact that oncologists needextensive training in palliative care.

References

1. American Society of Clinical Oncology (1998) Cancer care duringthe last phase of life. J Clin Oncol 16:1986–1996

2. Barbera L, Paszat L, Qiu F (2008) End-of-life care in lung cancerpatients in Ontario: aggressiveness of care in the population and a

description of hospital admissions. J Pain Symptom Manage35:267–274

3. Davies E, Linklater KM, Jack RH, Clark L, Moller H (2006) Howis place of death from cancer changing and what affects it?Analysis of cancer registration and service data. Br J Cancer95:593–600

4. Elsayem A, Swint K, Fisch MJ, Palmer JL, Reddy S, Walker P,Zhukovsky D, Knight P, Bruera E (2004) Palliative care inpatientservice in a comprehensive cancer center: clinical and financialoutcomes. J Clin Oncol 22:2008–2014

5. Ferris FD, Bruera E, Cherny N, Cummings C, Currow D,Dudgeon D, Janjan N, Strasser F, von Gunten CF, Von RoennJH (2009) Palliative cancer care a decade later: accomplishments,the need, next steps—from the American Society of ClinicalOncology. J Clin Oncol 27:3052–3058

6. Grundy E, Mayer D, Young H, Sloggett A (2004) Livingarrangements and place of death of older people with cancerin England and Wales: a record linkage study. Br J Cancer91:907–912

7. Hui D, Elsayem A, Palla S, De La Cruz M, Li Z,Yennurajalingam S, Bruera E (2010) Discharge outcomesand survival of patients with advanced cancer admitted to anacute palliative care unit at a comprehensive cancer center. JPalliat Med 13:49–57

8. Lagman R, Rivera N, Walsh D, LeGrand S, Davis MP (2007)Acute inpatient palliative medicine in a cancer center: clinicalproblems and medical interventions—a prospective study. Am JHosp Palliat Care 24:20–28

9. Rigby A, Krzyzanowska M, Le LW, Swami N, Coe G, Rodin G,Moore M, Zimmermann C (2008) Impact of opening an acutepalliative care unit on administrative outcomes for a generaloncology ward. Cancer 113:3267–3274

10. Tas F, Argon A, Disci R, Topuz E (2007) Pattern and outcome ofadmission to a medical oncology inpatient service. J Cancer Educ22:80–85

11. Yates M, Barrett A (2009) Oncological emergency admissions tothe Norfolk and Norwich University Hospital: an audit of currentarrangements and patient satisfaction. Clin Oncol (R Coll Radiol)21:226–233

1234 Support Care Cancer (2010) 18:1231–1234