1. More intense interventions at the end-of-life for children with cancer was associated with a bimodal age distribution (children younger than 5 and older than 15) and with hematologic malignancies.
2. African American, Asian American, and Hispanic children were more likely to die in the hospital, a marker of higher intensity of care at the end of life.
Evidence Rating Level: 2 (Good)
Study Rundown: Though much attention has been given to tempering the intensity of end-of-life care for adults with terminal diseases in order to more appropriately align with patient goals, little investigation on the same topic had been done for children with terminal diagnoses. In this study, investigators sought to identify the frequency of intense end-of-life interventions in children with cancer. Investigators used ICD-9 codes to identify various intensive therapies, including ICU admissions, intubations, mechanical ventilation, tracheostomy placement, dialysis, cardiopulmonary resuscitation, chemotherapy used in the last days of life, and death in the hospital. Additional demographic information was collected, including patient age, race, type of malignancy (hematologic versus solid), and proximity to the hospital. Results analysis revealed an association between end-of-life interventions and age younger than 5 or older than 15, as well as with hematologic malignancies. Additionally, African American, Asian American, and Hispanic children were more likely to have a hospital death. Though investigators note the rate of intervention was higher for children than for adults when compared to Medicare data, they rightfully admit this comparison is not necessarily appropriate given the more morbid nature of adult disease. Still, their findings affirm the need for earlier palliative intervention for children with terminal disease.
Relevant Reading: Symptoms and Suffering at the End of Life in Children with Cancer
In-Depth [retrospective cohort]: Data was collected from discharge records and death certificates for children ages 0 to 21 with cancer diagnosed within 6 months of death or cancer as the cause of death from 2000 to 2011 in the state of California. Data assessed included ICU admissions, intubation, mechanical ventilation, tracheostomy placement, gastrostomy-tube placement, hemodialysis, or CPR in the last 30 days of life, IV chemotherapy in the last 14 days of life, and hospital death. Sociodemographic data was also collected, including death age, sex, race/ethnicity, median household income. The most common interventions included hospital death (63%), ICU admissions (20%), and intubation or mechanical ventilation (20%). Multivariable regression revealed an association between hospital death in children younger than age 5 at time of death (OR=1.72, p<.0001) and between ages 15 and 21 (OR=1.42, p=.0006) as compared to children ages 5-9. Hospital death was increased in African American (OR=1.43, p=.02), Asian American (OR=1.32, p=.04), and Hispanic (OR=1.43, p<.0001) as compared to non-Hispanic white children. Children with hematologic malignancies had a significantly higher rate of hospital death (OR=3.56, p<.0001), medical intensity (OR=2.31, p<.0001), greater than or equal to 2 intensity indicators (OR=2.25, p<.0001), and inpatient IV chemotherapy (OR=2.21, p<.0001) as compared to children with solid tumors.
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