Rates of high-intensity end-of-life care have remained high among children with cancer, especially those with hematologic malignancies, according to a retrospective analysis conducted in Ontario, Canada.
Previous studies have shown that children often experience high symptom burden at the end of life, both due to advanced disease and high-intensity medical care.
“High-intensity medical care at the end of life is variably defined in the literature but includes measures during the last month of life such as in-hospital deaths, ICU admissions, ED visits and IV chemotherapy administration,” Sumit Gupta, MD, PhD, FRCPC, staff oncologist and clinician investigator in the division of hematology/oncology at Hospital for Sick Children in Ontario, Canada, and colleagues wrote. “Each of these events can be appropriate in individual cases; however, in the aggregate, they may indicate a tendency to focus on anticancer treatment at the expense of palliative care.”
Because most data on end-of-life care in children is derived from single-center studies, Gupta and colleagues determined predictors of and trends in high-intensity end-of-life care in children by linking population-based clinical and health services databases from Ontario.
Researchers defined high-intensity care as IV chemotherapy within 14 days of death, more than one ED visit, and more than one hospitalization or ICU admission within 30 days of death. Researchers also evaluated most-invasive care, such as use of mechanical ventilation within 14 days of death.
The analysis included data from 815 children (56.6% boys) who died of childhood cancer between 2000 and 2012. Cancer types included solid tumors (35.6%), hematologic cancers (32.5%) and central nervous system tumors (31.9%).
Overall, 331 children (40.6%) received high-intensity end-of-life care, and 354 children (43.4%) died in the hospital setting. ICU admission within 30 days of death was the most common form of high-intensity care (21.7%), followed by hospitalization within 30 days of death (17.6%), more than one ED visit within 30 days of death (8.6%) and IV chemotherapy receipt within 14 days of death (7.9%).
Children with hematologic malignancies were more likely than children with solid tumors to receive any component of high-intensity care (OR = 2.5; 95% CI, 1.8-3.6).
Further, 16.7% of children received mechanical ventilation within 14 days of death. Most-invasive end-of-life care was more common among girls (OR = 1.6; 95% CI, 1.1-2.4), patients with hematologic malignancies (OR = 5.1; 95% CI, 3.1-8.3), and patients who died in middle (2005-2008, OR = 2.2; 95% CI, 1.3-3.6) and later time periods (2009-2012, OR = 2.3; 95% CI, 1.4-3.8).
One hundred ten deaths (12.3%) were attributed to treatment-related mortality. All measures of high-intensity end-of-life care, except for ED visits and hospitalization, were more common among children who died of treatment-related mortality than of cancer-related causes.
Researchers compared their findings with a study conducted in adults, which showed a 22% rate of high-intensity care use at the end of life. This difference may reflect unique challenges associated with pediatric palliative oncology, Gupta and colleagues wrote.
“Most children are cured of their disease; pediatric providers comparatively have less experience initiating difficult discussions about end of life,” they wrote. “... Moreover, predictive timing of death, particularly in children who have rebounded from multiple medical crises, can be challenging. Finally, pressures from caregivers to purse treatments felt by treating clinicians to be futile may also play a role. Together, these factors may contribute to a higher probability of intensive interventions until the point of death.
“Future studies should focus on exploring the relationship between high-quality palliative care and high-intensity end-of-life care, particularly in vulnerable populations,” the researchers added. – by Alexandra Todak
Disclosure: Gupta reports no relevant financial disclosures. One researcher reports stock ownership in MedCurrent. Another researcher reports a consultant/advisory role with United Healthcare and royalties on patents licensed to UpToDate.