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Early integration of palliative care in patients with pancreatic cancer: A retrospective study for quality improvement.

72 Background: Many patients with pancreatic cancer receive palliative care only at the end of life despite the fact that the course of illness is plagued with physical, emotional symptoms and existential distress. There is strong evidence that combining palliative care with standard cancer treatment improves quality of life for those patients with in metastatic cancer and in some cases can help extend survival. Early incorporation of palliative care for patients with incurable cancer is an important focus for quality improvement.


METHODS
The purpose of this quality improvement study was to describe quality indicators for palliative care, and discover when palliative care was introduced during the course of illness in patients with pancreatic cancer. Domains of palliative care identified by the National Consensus Project and the National Quality Framework, provided the framework for this study. A retrospective medical record review of patients with pancreatic cancer treated at the Dana-Farber Cancer Institute (DFCI) between January 2009 to December 2011 was conducted. Time variables relevant to disease course, and palliative care referrals were collected. Other key variables included: the reason for, and frequency and timing of, palliative care discussions.


RESULTS
Medical records from 150 DFCI patients were reviewed in which the mean length of care from first visit to last note (typically death) was 414 days (SD=347). 52 (35%) records included documentation of a palliative care discussion and the majority of those occurred at the time of disease progression. Prognosis discussions were documented after a mean 177 (SD=285) days and a palliative care consult was made on average at day 343 (SD=301). Of those consults, the large majority (82%) were requested for symptom management.


CONCLUSIONS
Despite evidence and standards of care that support early palliative care discussions and subsequent referrals for palliative care consults, these findings suggest such events occurred late in the trajectory and care of patients with pancreatic cancer. Future quality work and training will address provider and health system variables that can promote discussions and consults.