How does an acute palliative care unit work in a comprehensive cancer center?

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Sebastiano Mercadante, Yasmine Grassi, Claudio Adile, Giorgio Sapienza, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6638128/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Sep, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract PURPOSE: The aim of this study was, other than assessing clinical outcomes after a comprehensive palliative care treatment in APCU, to report the activity and functioning of APCU in influencing subsequent care trajectory and settings of patients with advanced cancer. PATIENTS AND METHODS: A consecutive sample of patients with cancer who were admitted to an acute palliative care unit (APCU) was prospectively assessed. All patients underwent comprehensive palliative care treatment. At admission (T0), patients’ demographics, reasons for admission, referral, recent anticancer treatments, being on/off treatment or uncertain. Subsequent referral to next care settings and the pathway of oncologic treatment was re-considered. Symptom intensity was measured by Edmonton Symptom Assessment Scale (ESAS). RESULTS: Five-hundred and twenty patients were surveyed. Clinical deterioration was the most frequent indication for APCU admission. Most admissions were planned (60.8%). At discharge a significant decrease of the number of “on therapy” patients was reported, and concomitantly the number of “off-therapy” patients increased (p<0.0005) in comparison with data recorded at admission. A significant number of patients was assigned to a palliative care setting, including home palliative care or hospiceat time of discharge (p<0.0005). All ESAS items significantly improved during admission were significant. Being “off therapy” was independently associated with a lower Karnofsky (p=0.002), higher global ESAS at discharge (p=0.032), and discharge to a palliative setting (hospice or home palliative care); (p<0.0005). CONCLUSION: Data from the present study has shown that APCU results in a cross-road for patients with advanced cancer, allowing selection for transition of care advanced cancer acute palliative care unit home palliative care Figures Figure 1 INTRODUCTION Most patients with advanced cancer require palliative care along their course of disease. Primary and secondary palliative care involves basic and specialist clinicians providing consultation and specialized treatment, respectively. Tertiary palliative care addresses the most complex cases through clinical practice, research, and education ( 1 , 2 ). Palliative care is traditionally provided at home, in hospices, or via mobile hospital teams. However, in most countries, specialised palliative care is available only for the final 2–3 weeks of life. The mean survival of cancer patients followed by a home palliative care team has been reported to be 6–7 weeks ( 3 ). Studies indicate that, in the three months preceding hospice admission, many patients spend approximately five weeks in hospital, with around 50% receiving chemotherapy. Most patients had a relevant symptom burden and were undertreated [4). In the last months of life most patients spent about one-third of this period in hospital, with half of them receiving chemotherapy in the last month of life [5) Reports from the United States indicate that the median interval between palliative care referral and death is under two months ( 6 ). Thus, patients may receive aggressive oncologic treatments even at the end of life and oncologists often administer aggressive or futile treatments due to limited palliative care experience ( 7 – 10 ). Indeed, early palliative referrals were associated with more inpatient hospice utilization, less aggressive end of life care and less intensive medical care, improving quality outcomes and cost savings at the end of life ( 11 , 12 ), Patients who received aggressive end-of-life care incur 43% higher costs than those managed non aggressively. Palliative consultation may partially offset these costs and offer resultant savings ( 13 ). Aggressive cancer care at the end-of-life indicates multiply costs during the last month of life. Palliative care instituted more than 90 days before death reduces chemotherapy in the last month of life ( 14 ). Despite recommendations that early palliative care be offered to all patients with metastatic cancer, palliative care services remain underutilized. In the last years, palliative carehas evolved rapidly with growing information, experience, and models of care settings, contributing to high variability in practice and outcomes. Recent advancements in palliative care highlight the importance of integrating it into settings beyond traditional home and hospice care, such as Acute Palliative Care Units (APCUs), to intercept cancer patients early in the course of disease, rather than limiting this intervention in the last weeks of life. These units serve as hubs for managing patients with advanced diseases, addressing clinical complications, and reassessing treatment strategies, including the continuation, modification, or cessation of oncological therapies. APCUs provide specialised, timely palliative care with multidisciplinary expertise, enabling swift therapeutic adjustments based on continuous clinical assessments, imaging studies, and specialist consultations. A busy oncological unit is unlikely to be the best option, and frequently does not have beds available ( 15 ). In addition, an APCU may prevent inappropriate admission to other units, which implies unjustifiable costs for non-specialistic intervention ( 16 ). These units can meet the global needs of cancer patients to resolve the many physical and psychological problems occurring at any stage of disease, during both the active treatment or the advanced stage of disease, redirecting the care pathway, preventing overtreatment, and, of course, intervening in the delicate phase of end of life ( 17 – 23 ). Several studies have reported the positive outcomes of APCUs, that have been shown to provide better outcomes and cost saving than palliative care consultation services ( 19 – 28 ). However, data concerning the operation of an APCU have been poorly described. The aim of this study was to report the activity and operation of APCU in influencing subsequent care trajectory and settings of patients with advanced cancer, thus optimizing the local resources. The secondary outcome was to assess clinical changes after a comprehensive palliative care treatment in APCU. METHODS The study received approval from the Institutional Review Board (Comitato Etico Provinciale di Palermo 1), and was in accordance with the Declaration of Helsinki.. Informed consent was obtained from all participants. The study was conducted within an APCU, devoted to teaching and research, and affiliated with the University of Palermo. The unit comprises 12 beds and has been operational for over 25 years within a comprehensive cancer centre. The characteristics of this unit have been described elsewhere ( 23 ). The unit is integrated with a 10-bed hospice, located in an adjacent wing, and a comprehensive home palliative care program. Patients A consecutive sample of cancer patients admitted to the APCU was prospectively assessed over 13 months. All patients underwent comprehensive palliative care treatment, including continuous symptom assessment and personalized therapeutic interventions based on the specific needs and characteristics of patients. Upon discharge, patient status was reassessed, when necessary, through imaging studies and oncological consultations to determine subsequent care pathways, including continued oncological treatment, cessation of therapy, or transition to hospice or home-based palliative care. Data Collection Demographic data (age, gender, primary diagnosis), performance status, and reasons for admission (pain, opioid-related issues, clinical deterioration, chemotherapy toxicity, symptom control, or end-of-life care) were recorded. Referral sources included home settings, hospital units, outpatient day hospitals, or other medical institutions. Admissions were categorised as planned or unplanned, with readmission rates and time from the previous admission were recorded. Data on chemotherapy and other oncological treatments within the last 30 days were collected, alongside patient status at admission (on-treatment, off-treatment, or uncertain). At admission and at time of discharge (TX) (or the day before death), symptom burden was assessed using the Edmonton Symptom Assessment Scale (ESAS), a validated tool measuring symptom severity on a 0–10 scale, sensitive to changes produced by a treatment ( 30 , 31 ). Subsequent referral to next care settings (discharge home, home palliative care, hospice, other units), and the pathway of oncologic treatment were re-considered (on/off, uncertain). Reporting was based on STROBE for observational studies Statistical Analysis Continuous data were expressed as mean ± SD. Frequency analysis was performed using the Pearson’s chi-square test and Fisher exact test, as needed, with Bonferroni ‘s test correction for multiple comparisons. The paired Wilcoxon signed-rank test was used to compare pain intensity scores and symptom intensity scores in the time intervals. The one-way analysis of variance (ANOVA) was used for other analysis with parametric variables. Multinomial logistic regression analysis examined the correlation between the different clinical parameters of patients (independent variables), and treatment patient groups and discharge characteristics (dependent variable). Oodds ratios (ORs) and 95% confidence intervals were reported. Data were analysed by IBM SPSS Software 24 version (IBM Corp., Armonk, NY, USA). All p-values were two-sided and p < 0.05 was considered statistically significant. RESULTS Five-hundred and twenty patients admitted to an APCU during the study period were surveyed. The characteristics of patients are reported in Table 1. Some data were not recorded for all the items. About 11% of patients (n.60) died during their stay in the APCU. Admission Clinical deterioration was the most frequent indication for APCU admission (n. 251, 48.3%), followed by uncontrolled pain (n.184, 35.4%), symptom control (n. 181, 34.8%), toxicity (n.32, 6.2%), and end of life issues (n.60, 11.5%) (multiple choices). Planned admissions accounted for 60.8%, while 29.6% were emergency admissions. Readmission rates were 9.6%, predominantly due to uncontrolled pain (60%). The mean number of days from the last admission was 54.2 days (range 7-540). At admission, 309 patients (59.6%) had received oncological treatment in the preceding 30 days Discharge By discharge a significant decrease of the number of “on therapy” patients was reported, and concomitantly the number of “off-therapy” patients increased (p<0.0005) in comparison with data recorded at admission. A significant number of patients was assigned to a palliative care setting, including home palliative care or hospice at time of discharge (p<0.0005). Data regarding on how the patient was considered for treatment purposes (on/off, or uncertain), the setting where patients were previously cared before referral, and decision making on next care pathways at discharge from APCU, are detailed in Table 1 and Figure 1. The most relevant data was that the number of patients who were discharged home without specialized home palliative care significantly decreased at discharge (P<0.005), in favor of a significant number of patients who were transferred to hospice. Of interest, of 75 referrals from home palliative care, 40 patients were discharged to continue specialized home palliative care, 17 patients were transferred to hospice, 5 patients were transferred to other units, and 13 patients died in the APCU. Thus, most patients who were discharged to home palliative care, were referred from other settings. Patients referred by home palliative care were more likely to be transferred to hospice (P<0.005). Symptom intensity Symptom intensity at discharge improved significantly across all ESAS domains (p<0.0005) (Table 2). Multivariate analysis confirmed associations between an “off-therapy” status and lower Karnofsky scores, higher ESAS scores at discharge, and increased referral to palliative care settings (OR=1.047, 95% CI=1.017–1.078; p=0.002). DISCUSSION This study presents significant findings regarding various aspects of operativity and activities of an APCU. As expected, the implementation of comprehensive palliative care resulted in a substantial reduction in symptom burden. Notably, the APCU functions as a critical hub for decision-making regarding the transition to specialized palliative care in hospice or at home, as well as for the discontinuation of anticancer treatments. Admission to the APCU facilitates reassessment, including imaging studies and bedside consultations with oncologists overseeing the patients' care, thereby enabling well-informed decisions on withdrawing anticancer treatments. This process often leads to a substantial shift in the clinical trajectory. Indeed, approximately 68% of patients who were receiving active therapy at the time of admission were subsequently discharged home to continue their treatment, underscoring the APCU's role in improving the clinical condition of some patients to the extent that they can resume anticancer therapies. Several studies have demonstrated that patients admitted to an APCU experience significant reductions in symptom burden within a short period following comprehensive interventions. These interventions encompass medication management and support for physical, emotional, psychological, social, and spiritual challenges. The resultant outcomes include high levels of patient satisfaction, significant pain relief, and minimal adverse events ( 18 , 28 , 32 – 36 ). These findings align with those of the present study, which confirms that intensive palliative care provided within an APCU effectively alleviates symptom distress in patients with advanced cancer within a short timeframe. Beyond symptom control, the APCU plays a pivotal role in the patient care continuum, serving as a hospital-based hub for individuals with advanced disease. It facilitates clinical improvement to enable patients to continue their anticancer treatments or re-evaluate their disease status to determine the most appropriate course of action—whether to withhold, withdraw, initiate, continue, or modify active treatments ( 16 ). In many cases, specific imaging studies are required to inform these decisions, allowing for meaningful discussions with patients and their families based on new clinical findings ( 37 ). Consequently, APCUs serve as an essential bridge between acute care hospitals and existing palliative care services. No other palliative care setting possesses the capability to perform such complex activities and effectively redistribute patients within the palliative care network, including home-based palliative care and hospice services. The primary limitation of this study is its reliance on a single-centre experience within a high-volume APCU, which admits approximately 500 patients per year and is affiliated with a 10-bed hospice operated by the same clinical team. This hospice primarily accommodates patients who are no longer eligible for anticancer treatment, as well as those with other incurable non cancer conditions ( 38 ). Such an integrated model has not been previously described in the literature. Additionally, the absence of a comparative palliative care setting, such as consultation services, hospice care, or home-based care, may be a potential limitation. However, direct comparisons may be inherently challenging due to differences in patient profiles, available facilities, and levels of clinical expertise. In conclusion, an APCU staffed by specialised personnel provides comprehensive palliative care, enabling timely decision-making and rapid therapeutic adjustments based on continuous clinical observation, specialist assessments, and strict monitoring of complex cases. The consistency and expertise of the APCU team, gained through extensive experience managing a diverse range of clinical conditions in a high-volume unit, contribute to improved patient outcomes. Compared to a busy oncology ward, the APCU facilitates more structured hospital admissions and optimises care trajectories for patients with advanced cancer ( 15 ). The findings of this study demonstrate that the APCU serves as a critical nexus for patients with advanced cancer, potentially preventing inappropriate admissions to other hospital units, thereby avoiding unnecessary costs associated with non-specialist interventions. Furthermore, the APCU team plays a crucial role in providing consultations, expert guidance, and influencing care practices across other hospital departments, in addition to admitting complex cases requiring specialised palliative care. Future research should be conducted in similar APCU settings with comparable facilities to validate these preliminary single-centre findings. Declarations No conflict of interest No funding No use of AI Author Contribution Authors contributionSM: Conceptualization; supervision, writing original draftYG, CA, GS InvestigationAL Data curationAC Formal analysis;All: Writing - review & editing. References Bruera E, Hui D. (2021) Conceptual models for integrating palliative care at cancer centers. J Palliat Med 15:1261–9. Hui D, Paiva BSR, Paiva CE. (2023) Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: "Care Anywhere, Anytime". Curr Treat Options Oncol;24:1–11. Mercadante S, Valle A, Porzio G, et al. (2011) How do cancer patients receiving palliative care at home die? A descriptive study. J Pain Symptom Manage 42:702–9. Mercadante S, Valle A, Sabba S, et al. (2013) Pattern and characteristics of advanced cancer patients admitted to hospice in Italy. Support Care Cancer 21:935–9. Rocque GB, Barnett AE, Illig L, et al. (2013) Inpatient hospitalization of oncology patients: are we missing an opportunity for end-of-life care? J Oncol Pract 9:51–4 Cheng WW, Willey J, Palmer JL, Zhang T, Bruera E. (2005) Interval between palliative care referral and death among patients treated at a comprehensive cancer center. J Palliat Med 8:1025–32. 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(2016) The Costs of Waiting: Implications of the Timing of Palliative Care Consultation among a Cohort of Decedents at a Comprehensive Cancer Center. J Palliat Med 19:69–75. Cheung MC, Earle CC, Rangrej J. (2015) Impact of aggressive management and palliative care on cancer costs in the final month of life Cancer. 121:3307–15. Davis MP, Vanenkevort FA, Elder A. (2023) The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs. Am J Hosp Palliat Care 40:52–60. Mercadante S, Marchetti P, Adile C, et al. (2018) A Characteristics and care pathways of advanced cancer patients in a palliative-supportive care unit and an oncological ward. Support Care Cancer 26:1961–6. Mercadante S, Zimmermann C, Lau J, Walsh D. (2025) Should an Acute Palliative Care Unit be Mandatory for Cancer Centers and Tertiary Care Hospitals? J Pain Symptom Manage. 69:e70-e77. Hui D, Elsayem A, Palla S, et al. (2010) Discharge outcomes and survivalof patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center. J Palliat Med 12:49–57. Rigby A, Krzyanowska M, Le LW, et al. (2008) Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward. J Clin Oncol 113:3267–74. Smith T, Coyne P, Cassel B, et al. (2003) A high volume specialist palliative care unit and team may reduce in-hospital end-of life care costs. J Palliat Med 6:699–705. Braiteh F, El Osta B, Palmer L, Reddy S, Bruera E. (2007) Characteristics, findings, and outcomes of palliative care inpatient consultations at a comprehensive cancer center. J Palliat Med 10:948–55. Lagman R, Rivera N, Walsh D, LeGrand S, Davis M. (2007) Acute inpatient palliative medicine in a cancer center: clinical problems and medical interventions. A prospective study. J Palliat Med 24: 20–8. Bruera E, Hui D. (2010) Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care. J Clin Oncol 28:4013–7. Mercadante S, Villari P, Ferrera P. (2003) A model of acute symptom control unit: Pain Relief and Palliative Care Unit of La Maddalena Cancer Center. Support Care Cancer. 11:114–9. Smith T, Coyne P, Cassel B, et al. (2003) A high volume specialist palliative care unit and team may reduce in-hospital end-of life care costs. J Palliat Med 6:699–705. Shin SH, Hui D, Chisholm GB, et al. (2013) Characteristics and outcomes of patients admitted to the acute palliative care unit from Emergency center. J Pain Symptom Manage 47:1028–34. Gardiner C, Gott M, Ingleton C, Seymour J, Cobb M, Noble B, et al Extent of palliative care need in theacute hospital setting: a survey of two acute hospital in the UK. Palliat Med 2012;27:76–83. Nathaniel JD, Garrido M, Chai EJ, Goldberg G, Goldstein NE. Cost saving associated with an inpatientpalliative care unit: results from the first two years. J Pain Symptom Manage 2015; 50:147–54, Mercadante S, Adile A, Caruselli A, et al. The Palliative-Supportive Care Unit in a Comprehensive Cancer Center as Crossroad for Patients' Oncological Pathway PLoS One. 2016;11:e0157300 Chang VT, Hwang SS, Feurman M. Validation of the Edmonton Symptom Assessment Scale. Cancer 2000; 88:2164–71. Hui D, Bruera E.The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments. J Pain Symptom Manage. 2017;53:630–43. Tagami K, Chiu SW, Kosugi K, et al. Cancer Pain Management in Patients Receiving Inpatient Specialized Palliative Care Services. J Pain Symptom Manage 2024;67:27–38. Jung EH, Lee SW, Kim YJ. Clinical Outcomes of Operating an Acute Palliative Care Unit at a Comprehensive Cancer Center. JCO Oncol Pract 2022;18:1661–71. Bryson J, Coe G, Swami N, et al: Administrative outcomes five years after opening an acute palliative care unit at a comprehensive cancer center. J Palliat Med 2010;13:559–65. Cohen SR, Boston P, Mount BM, Porterfield P: Changes in quality of life following admission to palliative care units. Palliat Med 2001;15:363–71. Ng K, von Gunten CF: Symptoms and attitudes of 100 consecutive patients admitted to an acute hospice/palliative care unit. J Pain Symptom Manage 1998;16: 307–16. Mercadante S, Grassi Y, Cascio AL. A month of diagnostic imaging studies in an acute supportive/palliative care unit. Support Care Cancer 2024;32:741. Mercadante S, Giuliana F, Bellingardo R, et al. Pattern and characteristics of patients admitted to a hospice connected with an acute palliative care unit in a comprehensive cancer center. Support Care Cancer 2022;30:2811–9. Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Cite Share Download PDF Status: Published Journal Publication published 24 Sep, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 02 Jul, 2025 Reviews received at journal 02 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviewers agreed at journal 01 Jul, 2025 Reviewers agreed at journal 22 Jun, 2025 Reviewers invited by journal 18 Jun, 2025 Editor assigned by journal 18 Jun, 2025 Submission checks completed at journal 16 May, 2025 First submitted to journal 11 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6638128","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473198642,"identity":"6da4167f-b5f5-4a5a-ac03-a3854b7a418c","order_by":0,"name":"Sebastiano 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Primary and secondary palliative care involves basic and specialist clinicians providing consultation and specialized treatment, respectively. Tertiary palliative care addresses the most complex cases through clinical practice, research, and education (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePalliative care is traditionally provided at home, in hospices, or via mobile hospital teams. However, in most countries, specialised palliative care is available only for the final 2\u0026ndash;3 weeks of life. The mean survival of cancer patients followed by a home palliative care team has been reported to be 6\u0026ndash;7 weeks (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Studies indicate that, in the three months preceding hospice admission, many patients spend approximately five weeks in hospital, with around 50% receiving chemotherapy. Most patients had a relevant symptom burden and were undertreated [4). In the last months of life most patients spent about one-third of this period in hospital, with half of them receiving chemotherapy in the last month of life [5) Reports from the United States indicate that the median interval between palliative care referral and death is under two months (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Thus, patients may receive aggressive oncologic treatments even at the end of life and oncologists often administer aggressive or futile treatments due to limited palliative care experience (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIndeed, early palliative referrals were associated with more inpatient hospice utilization, less aggressive end of life care and less intensive medical care, improving quality outcomes and cost savings at the end of life (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), Patients who received aggressive end-of-life care incur 43% higher costs than those managed non aggressively. Palliative consultation may partially offset these costs and offer resultant savings (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Aggressive cancer care at the end-of-life indicates multiply costs during the last month of life. Palliative care instituted more than 90 days before death reduces chemotherapy in the last month of life (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Despite recommendations that early palliative care be offered to all patients with metastatic cancer, palliative care services remain underutilized.\u003c/p\u003e \u003cp\u003eIn the last years, palliative carehas evolved rapidly with growing information, experience, and models of care settings, contributing to high variability in practice and outcomes. Recent advancements in palliative care highlight the importance of integrating it into settings beyond traditional home and hospice care, such as Acute Palliative Care Units (APCUs), to intercept cancer patients early in the course of disease, rather than limiting this intervention in the last weeks of life. These units serve as hubs for managing patients with advanced diseases, addressing clinical complications, and reassessing treatment strategies, including the continuation, modification, or cessation of oncological therapies. APCUs provide specialised, timely palliative care with multidisciplinary expertise, enabling swift therapeutic adjustments based on continuous clinical assessments, imaging studies, and specialist consultations. A busy oncological unit is unlikely to be the best option, and frequently does not have beds available (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In addition, an APCU may prevent inappropriate admission to other units, which implies unjustifiable costs for non-specialistic intervention (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These units can meet the global needs of cancer patients to resolve the many physical and psychological problems occurring at any stage of disease, during both the active treatment or the advanced stage of disease, redirecting the care pathway, preventing overtreatment, and, of course, intervening in the delicate phase of end of life (\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Several studies have reported the positive outcomes of APCUs, that have been shown to provide better outcomes and cost saving than palliative care consultation services (\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, data concerning the operation of an APCU have been poorly described. The aim of this study was to report the activity and operation of APCU in influencing subsequent care trajectory and settings of patients with advanced cancer, thus optimizing the local resources. The secondary outcome was to assess clinical changes after a comprehensive palliative care treatment in APCU.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e The study received approval from the Institutional Review Board (Comitato Etico Provinciale di Palermo 1), and was in accordance with the Declaration of Helsinki.. Informed consent was obtained from all participants. The study was conducted within an APCU, devoted to teaching and research, and affiliated with the University of Palermo. The unit comprises 12 beds and has been operational for over 25 years within a comprehensive cancer centre. The characteristics of this unit have been described elsewhere (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The unit is integrated with a 10-bed hospice, located in an adjacent wing, and a comprehensive home palliative care program.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eA consecutive sample of cancer patients admitted to the APCU was prospectively assessed over 13 months. All patients underwent comprehensive palliative care treatment, including continuous symptom assessment and personalized therapeutic interventions based on the specific needs and characteristics of patients. Upon discharge, patient status was reassessed, when necessary, through imaging studies and oncological consultations to determine subsequent care pathways, including continued oncological treatment, cessation of therapy, or transition to hospice or home-based palliative care.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eDemographic data (age, gender, primary diagnosis), performance status, and reasons for admission (pain, opioid-related issues, clinical deterioration, chemotherapy toxicity, symptom control, or end-of-life care) were recorded. Referral sources included home settings, hospital units, outpatient day hospitals, or other medical institutions. Admissions were categorised as planned or unplanned, with readmission rates and time from the previous admission were recorded. Data on chemotherapy and other oncological treatments within the last 30 days were collected, alongside patient status at admission (on-treatment, off-treatment, or uncertain). At admission and at time of discharge (TX) (or the day before death), symptom burden was assessed using the Edmonton Symptom Assessment Scale (ESAS), a validated tool measuring symptom severity on a 0\u0026ndash;10 scale, sensitive to changes produced by a treatment (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Subsequent referral to next care settings (discharge home, home palliative care, hospice, other units), and the pathway of oncologic treatment were re-considered (on/off, uncertain). Reporting was based on STROBE for observational studies\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. Frequency analysis was performed using the Pearson\u0026rsquo;s chi-square test and Fisher exact test, as needed, with Bonferroni \u0026lsquo;s test correction for multiple comparisons. The paired Wilcoxon signed-rank test was used to compare pain intensity scores and symptom intensity scores in the time intervals. The one-way analysis of variance (ANOVA) was used for other analysis with parametric variables. Multinomial logistic regression analysis examined the correlation between the different clinical parameters of patients (independent variables), and treatment patient groups and discharge characteristics (dependent variable). Oodds ratios (ORs) and 95% confidence intervals were reported. Data were analysed by IBM SPSS Software 24 version (IBM Corp., Armonk, NY, USA). All p-values were two-sided and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFive-hundred and twenty patients admitted to an APCU during the study period \u0026nbsp;were surveyed. The characteristics of patients are reported in Table 1. Some data were not recorded for all the items. About 11% of patients (n.60) died during their stay in the APCU.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdmission\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Clinical deterioration was the most frequent indication for APCU admission (n. 251, 48.3%), followed by uncontrolled pain (n.184, 35.4%), symptom control (n. 181, 34.8%), toxicity (n.32, 6.2%), and end of life issues (n.60, 11.5%) (multiple choices). Planned admissions accounted for 60.8%, while 29.6% were emergency admissions. Readmission rates were 9.6%, predominantly due to uncontrolled pain (60%). The mean number of days from the last admission was 54.2 days (range 7-540). \u0026nbsp; At admission, 309 patients (59.6%) had received oncological treatment in the preceding 30 days\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDischarge\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;By discharge a significant decrease of the number of \u0026ldquo;on therapy\u0026rdquo; patients was reported, and concomitantly the number of \u0026ldquo;off-therapy\u0026rdquo; patients increased (p\u0026lt;0.0005) in comparison with data recorded at admission. A significant number of patients was assigned to a palliative care setting, including home palliative care or hospice at time of discharge (p\u0026lt;0.0005).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data regarding on how the patient was considered for treatment purposes (on/off, or uncertain), the setting where patients were previously cared before referral, and decision making on next care pathways at discharge from APCU, are detailed in Table 1 and Figure 1. The most relevant data was that the number of patients who were discharged home without specialized home palliative care significantly decreased at discharge (P\u0026lt;0.005), in favor of a significant number of patients who were transferred to hospice. \u0026nbsp;Of interest, of 75 referrals from home palliative care, 40 patients were discharged to continue specialized home palliative care, 17 patients were transferred to hospice, 5 patients were transferred to other units, and 13 patients died in the APCU. Thus, most patients who were discharged to home palliative care, were referred from other settings. Patients referred by home palliative care were more likely to be transferred to hospice (P\u0026lt;0.005).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSymptom intensity\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSymptom intensity at discharge improved significantly across all ESAS domains (p\u0026lt;0.0005) (Table 2). Multivariate analysis confirmed associations between an \u0026ldquo;off-therapy\u0026rdquo; status and lower Karnofsky scores, higher ESAS scores at discharge, and increased referral to palliative care settings (OR=1.047, 95% CI=1.017\u0026ndash;1.078; p=0.002).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study presents significant findings regarding various aspects of operativity and activities of an APCU. As expected, the implementation of comprehensive palliative care resulted in a substantial reduction in symptom burden. Notably, the APCU functions as a critical hub for decision-making regarding the transition to specialized palliative care in hospice or at home, as well as for the discontinuation of anticancer treatments. Admission to the APCU facilitates reassessment, including imaging studies and bedside consultations with oncologists overseeing the patients' care, thereby enabling well-informed decisions on withdrawing anticancer treatments. This process often leads to a substantial shift in the clinical trajectory. Indeed, approximately 68% of patients who were receiving active therapy at the time of admission were subsequently discharged home to continue their treatment, underscoring the APCU's role in improving the clinical condition of some patients to the extent that they can resume anticancer therapies.\u003c/p\u003e \u003cp\u003eSeveral studies have demonstrated that patients admitted to an APCU experience significant reductions in symptom burden within a short period following comprehensive interventions. These interventions encompass medication management and support for physical, emotional, psychological, social, and spiritual challenges. The resultant outcomes include high levels of patient satisfaction, significant pain relief, and minimal adverse events (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e). These findings align with those of the present study, which confirms that intensive palliative care provided within an APCU effectively alleviates symptom distress in patients with advanced cancer within a short timeframe.\u003c/p\u003e \u003cp\u003eBeyond symptom control, the APCU plays a pivotal role in the patient care continuum, serving as a hospital-based hub for individuals with advanced disease. It facilitates clinical improvement to enable patients to continue their anticancer treatments or re-evaluate their disease status to determine the most appropriate course of action\u0026mdash;whether to withhold, withdraw, initiate, continue, or modify active treatments (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In many cases, specific imaging studies are required to inform these decisions, allowing for meaningful discussions with patients and their families based on new clinical findings (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Consequently, APCUs serve as an essential bridge between acute care hospitals and existing palliative care services. No other palliative care setting possesses the capability to perform such complex activities and effectively redistribute patients within the palliative care network, including home-based palliative care and hospice services.\u003c/p\u003e \u003cp\u003eThe primary limitation of this study is its reliance on a single-centre experience within a high-volume APCU, which admits approximately 500 patients per year and is affiliated with a 10-bed hospice operated by the same clinical team. This hospice primarily accommodates patients who are no longer eligible for anticancer treatment, as well as those with other incurable non cancer conditions (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Such an integrated model has not been previously described in the literature. Additionally, the absence of a comparative palliative care setting, such as consultation services, hospice care, or home-based care, may be a potential limitation. However, direct comparisons may be inherently challenging due to differences in patient profiles, available facilities, and levels of clinical expertise.\u003c/p\u003e \u003cp\u003eIn conclusion, an APCU staffed by specialised personnel provides comprehensive palliative care, enabling timely decision-making and rapid therapeutic adjustments based on continuous clinical observation, specialist assessments, and strict monitoring of complex cases. The consistency and expertise of the APCU team, gained through extensive experience managing a diverse range of clinical conditions in a high-volume unit, contribute to improved patient outcomes. Compared to a busy oncology ward, the APCU facilitates more structured hospital admissions and optimises care trajectories for patients with advanced cancer (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The findings of this study demonstrate that the APCU serves as a critical nexus for patients with advanced cancer, potentially preventing inappropriate admissions to other hospital units, thereby avoiding unnecessary costs associated with non-specialist interventions. Furthermore, the APCU team plays a crucial role in providing consultations, expert guidance, and influencing care practices across other hospital departments, in addition to admitting complex cases requiring specialised palliative care. Future research should be conducted in similar APCU settings with comparable facilities to validate these preliminary single-centre findings.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003eNo conflict of interest\u003c/p\u003e \u003cp\u003eNo funding\u003c/p\u003e \u003cp\u003eNo use of AI\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors contributionSM: Conceptualization; supervision, writing original draftYG, CA, GS InvestigationAL Data curationAC Formal analysis;All: Writing - review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBruera E, Hui D. (2021) Conceptual models for integrating palliative care at cancer centers. J Palliat Med 15:1261\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHui D, Paiva BSR, Paiva CE. (2023) Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: \"Care Anywhere, Anytime\". Curr Treat Options Oncol;24:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercadante S, Valle A, Porzio G, et al. (2011) How do cancer patients receiving palliative care at home die? A descriptive study. J Pain Symptom Manage 42:702\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercadante S, Valle A, Sabba S, et al. (2013) Pattern and characteristics of advanced cancer patients admitted to hospice in Italy. Support Care Cancer 21:935\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocque GB, Barnett AE, Illig L, et al. (2013) Inpatient hospitalization of oncology patients: are we missing an opportunity for end-of-life care? J Oncol Pract 9:51\u0026ndash;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng WW, Willey J, Palmer JL, Zhang T, Bruera E. (2005) Interval between palliative care referral and death among patients treated at a comprehensive cancer center. 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The Palliative-Supportive Care Unit in a Comprehensive Cancer Center as Crossroad for Patients' Oncological Pathway PLoS One. 2016;11:e0157300\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang VT, Hwang SS, Feurman M. Validation of the Edmonton Symptom Assessment Scale. Cancer 2000; 88:2164\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHui D, Bruera E.The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments. J Pain Symptom Manage. 2017;53:630\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTagami K, Chiu SW, Kosugi K, et al. Cancer Pain Management in Patients Receiving Inpatient Specialized Palliative Care Services. J Pain Symptom Manage 2024;67:27\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung EH, Lee SW, Kim YJ. Clinical Outcomes of Operating an Acute Palliative Care Unit at a Comprehensive Cancer Center. JCO Oncol Pract 2022;18:1661\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryson J, Coe G, Swami N, et al: Administrative outcomes five years after opening an acute palliative care unit at a comprehensive cancer center. J Palliat Med 2010;13:559\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen SR, Boston P, Mount BM, Porterfield P: Changes in quality of life following admission to palliative care units. Palliat Med 2001;15:363\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg K, von Gunten CF: Symptoms and attitudes of 100 consecutive patients admitted to an acute hospice/palliative care unit. J Pain Symptom Manage 1998;16: 307\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercadante S, Grassi Y, Cascio AL. A month of diagnostic imaging studies in an acute supportive/palliative care unit. Support Care Cancer 2024;32:741.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercadante S, Giuliana F, Bellingardo R, et al. Pattern and characteristics of patients admitted to a hospice connected with an acute palliative care unit in a comprehensive cancer center. Support Care Cancer 2022;30:2811\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"advanced cancer, acute palliative care unit, home palliative care","lastPublishedDoi":"10.21203/rs.3.rs-6638128/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6638128/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePURPOSE: The aim of this study was, other than assessing clinical outcomes after a comprehensive palliative care treatment in APCU, to report the activity and functioning of APCU in influencing subsequent care trajectory and settings of patients with advanced cancer.\u003c/p\u003e\n\u003cp\u003ePATIENTS AND METHODS: A consecutive sample of patients with cancer who were admitted to an acute palliative care unit (APCU) was prospectively assessed. All patients underwent comprehensive palliative care treatment. At admission (T0), patients’ demographics, reasons for admission, referral, recent anticancer treatments, being on/off treatment or uncertain. Subsequent referral to next care settings and the pathway of oncologic treatment was re-considered. Symptom intensity was measured by Edmonton Symptom Assessment Scale (ESAS).\u003c/p\u003e\n\u003cp\u003eRESULTS: Five-hundred and twenty patients were surveyed. Clinical deterioration was the most frequent indication for APCU admission. Most admissions were planned (60.8%). At discharge a significant decrease of the number of “on therapy” patients was reported, and concomitantly the number of “off-therapy” patients increased (p\u0026lt;0.0005) in comparison with data recorded at admission. A significant number of patients was assigned to a palliative care setting, including home palliative care or hospiceat time of discharge (p\u0026lt;0.0005). All ESAS items significantly improved during admission were significant. Being “off therapy” was independently associated with a lower Karnofsky (p=0.002), higher global ESAS at discharge (p=0.032), and discharge to a palliative setting (hospice or home palliative care); (p\u0026lt;0.0005).\u003c/p\u003e\n\u003cp\u003eCONCLUSION: Data from the present study has shown that APCU results in a cross-road for patients with advanced cancer, allowing selection for transition of care\u003c/p\u003e","manuscriptTitle":"How does an acute palliative care unit work in a comprehensive cancer center?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 10:17:50","doi":"10.21203/rs.3.rs-6638128/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-02T20:18:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T09:09:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T22:54:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210050328355256272076440843489300331815","date":"2025-07-01T04:54:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143716372915197440460452372584861642314","date":"2025-06-22T07:09:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T15:59:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T15:58:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-17T02:44:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-05-11T06:54:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6d9388c3-4db8-4694-a7e2-b45b92dde53d","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T16:00:08+00:00","versionOfRecord":{"articleIdentity":"rs-6638128","link":"https://doi.org/10.1007/s00520-025-09938-0","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-09-24 15:56:53","publishedOnDateReadable":"September 24th, 2025"},"versionCreatedAt":"2025-06-25 10:17:50","video":"","vorDoi":"10.1007/s00520-025-09938-0","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09938-0","workflowStages":[]},"version":"v1","identity":"rs-6638128","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6638128","identity":"rs-6638128","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}