Hospital-Based Palliative Care for Patients with Advanced Thoracic Malignancies: A Retrospective Cohort from a Tertiary Center

Hospital-Based Palliative Care for Patients with Advanced Thoracic Malignancies: A Retrospective Cohort from a Tertiary Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hospital-Based Palliative Care for Patients with Advanced Thoracic Malignancies: A Retrospective Cohort from a Tertiary Center Serena Barban, Rita Leporati, Lucia Trudu, Laura Scarabelli, Sofia Charis Bonilauri, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8013362/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose Patients with advanced thoracic malignancies carry heavy symptom burden and decline rapidly, yet hospital-based palliative care (PC) units are uncommon. We report outcomes of patients admitted to the University Hospital of Modena’s PC ward. Methods We conducted a retrospective, observational study of consecutive patients with advanced thoracic malignancies admitted to the PC ward between 2022 and 2024. Demographics, disease characteristics, most recent oncologic treatment, hospitalization details and outcomes were collected. Descriptive statistics, χ² test, Cox models and Kaplan–Meier were used. Results We included 144 patients (42.4% female; median age 75 years). NSCLC was the most frequent histology (68.1%), followed by SCLC (15.3%); 11.8% lacked histologic confirmation due to clinical deterioration. In the 30 days prior to admission, 36.1% received a systemic anticancer treatment and 72.9% had not received home-based PC. Most patients were transferred from other hospital wards; 22.2% were referred from home or other facilities. The median interval from diagnosis to PC admission was 4.8 months (95% CI, 1.1–11.7). Median overall survival (OS) from admission was 14 days (95% CI, 10–18). Palliative sedation was required in 25.7% of patients, mainly for refractory dyspnea and agitation. Overall, 29.9% were discharged after stabilization; discharge was more likely without target symptoms on PERSONS score (60.5% vs 37.6%; p = 0.02) and was associated with longer OS (45 vs 8 days; HR 0.12; 95% CI 0.08–0.21; p < 0.001). Conclusion A hospital-based PC ward offers symptoms management and end-of-life care despite late referrals. The inpatient setting ensures continuity of care and works as a discharge-oriented ward. lung cancer thoracic malignancies palliative care hospital-based hospice Figures Figure 1 Figure 2 Figure 3 1. Introduction Thoracic malignancies are common and confer substantial mortality and morbidity. Lung cancer, the most frequent thoracic cancer, remains the leading cause of cancer-related death worldwide despite advances in tumor biology and systemic therapies [ 1 ]. Symptom burden is typically high from both disease and treatment effects, and many patients present with advanced-stage disease. Consequently, there is a sustained need for palliative care (PC) across the illness trajectory, not only at the end of life but also alongside active oncologic treatment to provide comprehensive supportive care. Acute symptom crises and complications often necessitate hospitalization [ 2 ]. Yet dedicated inpatient hospital-based PC units are uncommon. PC is more frequently delivered through community hospices or home-care services, models that may be oriented toward end-of-life care and not always suited to patients requiring rapid titration of therapies, complex procedures, or multidisciplinary input. In this context, hospital-based PC wards can fill a critical gap by providing intensive symptom management, time-limited inpatient stabilization, and coordinated transitions to home or hospice. We report the experience of the Palliative Care Unit at Modena University Hospital, an inpatient ward embedded within the Oncology Center and closely integrated with the Medical Oncology wards and Day Hospital. The unit comprises 10 beds and admits patients with advanced oncologic and hematologic diseases who are not receiving active anticancer therapy. Referrals originate from other hospital wards, community services, or the Oncology Center’s emergency clinic; admission can also occur at the direct request of the treating oncologist or hematologist. Unlike many territorial hospices, which often require prior enrollment in home PC, our ward permits direct admission, thereby enabling access for patients without structured palliative support. Indications include complex symptom management, end-of-life care, palliative procedures, caregiver respite, and mitigation of social or logistical barriers to care. The ward is medically supervised and staffed by dedicated physicians, nurses, and healthcare assistants, with psychologists, physiatrists, and nutritionists available on call. On admission, all patients undergo standardized assessment using the Edmonton Symptom Assessment System (ESAS), the Palliative Prognostic (PaP) Score, and the PERSONS (Pain-Eating-Rehabilitation-Sleep-Oxygen-Nausea-Suffering) score [ 3 , 4 ]. The aim of the study is to describe the structure, admission pathways, and clinical role of a hospital-based PC unit in managing patients with thoracic malignancies, and to characterize patient profiles, indications for admission, and early outcomes within this care model. 2. Materials and methods We conducted a single-center, retrospective, observational cohort study of consecutive adults with advanced-stage thoracic malignancies admitted to the PC Ward of the University Hospital of Modena between January 2022 and September 2024. The PC ward is an inpatient unit embedded within the Oncology Center and staffed by a dedicated multidisciplinary team. Eligible patients were ≥ 18 years old with an advanced thoracic malignancy (e.g., Non-Small Cell Lung Cancer, Small Cell Lung Cancer, mesothelioma, thymic tumors) admitted to the PC ward during the study period. To avoid duplication, only the first PC-ward admission per patient was analyzed. Patients receiving active anticancer therapy at the time of admission were included; receipt of therapy within 30 days was captured as a covariate. Data were abstracted from the electronic medical record using a standardized case-report form and included: demographics (age, sex), disease features (histology, number and sites of metastases), clinical variables (Eastern Cooperative Oncology Group [ECOG] performance status [PS]; receipt of systemic anticancer therapy within 30 days prior to admission [yes/no; class recorded when available]; time from initial diagnosis to PC admission), and hospitalization details (referral source [other hospital wards, home, or other facilities], presence of home-care services before admission, indication for admission [e.g., dyspnea, pain], need for palliative sedation, palliative sedation indication and duration, discharge vs in-hospital death, and place of death). Symptoms prompting hospitalization were also recorded, and the ESAS score and PERSONS score were applied for their assessment. Upon admission, PaP score was also performed. All scales were administered as part of routine care at admission according to institutional procedures. The primary objective was to characterize clinical needs and hospitalization patterns among patients with advanced thoracic malignancies admitted to the PC ward, focusing on symptom burden, palliative interventions and end-of-life care. Overall survival (OS) was defined as the time from PC-ward admission to death from any cause; patients alive at last follow-up were censored on that date. Continuous variables are reported as median and interquartile range (IQR) or mean and standard deviation, as appropriate; categorical variables as counts and percentages. Group comparisons used Fisher’s exact or χ² tests for categorical variables and Wilcoxon rank-sum or t-tests for continuous variables, as appropriate. Survival functions were estimated using the Kaplan–Meier method and compared with the log-rank test. Hazard ratios (HRs) with 95% confidence intervals (CIs) were obtained from Cox proportional hazards models; proportional hazards assumptions were evaluated using Schoenfeld residuals. All tests were two-sided with α = 0.05. Analyses were performed in R (version 4.0.3; 2020-10-10). The extent of missingness for key variables was summarized; analyses used available data (complete-case). No imputation was performed. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Area Vasta Emilia Nord Ethic Committee. 3. Results 3.1 Patients’ characteristics We analyzed 144 consecutive patients with advanced thoracic cancers, representing 20% of all PC Ward admissions during the study period ( Table 1 ). The cohort included 61 women (42.4%) and 83 men (57.6%); median age was 75 years (IQR 68-80), with 52.8% aged ≥75 years. Non–small cell lung cancer (NSCLC) was the most common diagnosis (97/144, 67.4%), followed by small cell lung cancer (SCLC; 22/144, 15.3%) and mesothelioma (3/144, 2.1%); five patients (3.5%) had other histologies. In 17 patients (11.8%), a histologic diagnosis could not be obtained due to clinical instability. All patients had stage IV disease, with a median of 3 metastatic sites per patient. Common metastatic sites included lymph nodes (61.8%), bone (49.3%), liver (36.1%), lung (29.2%), brain (27.1%), and adrenal glands (22.2%); pleural involvement was recorded in 2.1%, and other sites in 21.5%. Within 30 days prior to PC-ward admission, 52 patients (36.1%) received systemic anticancer therapy: chemotherapy in 23 (44.2%), chemo-immunotherapy in 8 (15.4%), immunotherapy in 14 (26.9%), targeted therapy in 6 (11.6%), and other treatments in 1 (1.9%) ( Figure 1 ). Radiotherapy was delivered to 28 patients (19.4%) overall: eight (5.6%) in combination with systemic therapy and 20 (13.9%) without systemic therapy in the same timeframe. Table 1 . Baseline characteristics of patients admitted to the Palliative Care Unit Characteristics Patients n= 144, (%) Age, median (IQR), years ≥75 <75 75 (68-80) 76 (52.8) 68 (47.2) Sex Male Female 83 (57.6) 61 (42.4) ECOG PS 2 3 4 23 (16.0) 81 (56.2) 40 (27.8) Histology NSCLC SCLC Mesothelioma Other No diagnosis 97 (67.4) 22 (15.3) 3 (2.1) 5 (3.5) 17 (11.8) Metastatic sites Lung Lymph nodes Pleura Liver Bone Brain Adrenal gland Other 42 (29.2) 89 (61.8) 3 (2.1) 52 (36.1) 71 (49.3) 39 (27.1) 32 (22.2) 31 (21.5) Systemic anticancer treatment <30 days Chemotherapy Chemo-immunotherapy Immunotherapy Targeted therapy Other 52 (36.1) 23 (44.2)* 8 (15.4)* 14 (26.9)* 6 (11.6)* 1 (1.9)* Radiotherapy <30 days 20 (13.9) Systemic treatment + radiotherapy <30 days 8 (5.6) *% calculated on a total of 52 patients who received anticancer treatment in the last 30 days 3.2 Hospitalization characteristics Most patients (112/144, 77.8%) were transferred to the PC Ward from other hospital services, while 32 (22.2%) were admitted directly from home or residential facilities ( Table 2 ). Transfers originated mainly from the Oncological Medicine ward (43/144, 29.9%), the Oncology ward (23/144, 16.0%), and Internal Medicine ward (28/144, 19.4%); an additional 12 patients (8.3%) were transferred from other departments, and 6 (4.2%) were admitted directly from the Oncology Center emergency clinic. Before hospitalization, most patients were not enrolled in home-based PC (105/144, 72.9%). The leading indications for PC Ward admission were dyspnea (43/144, 29.9%), pain (35/144, 24.3%), neurologic symptoms (28/144, 19.4%), and global clinical deterioration (23/144, 16.0%); gastrointestinal symptoms (5/144, 3.5%) and jaundice (2/144, 1.4%) were less frequent. At admission, PaP score indicated a >70% 30-day mortality risk in 37 patients (25.7%), 30-70% in 57 (39.6%), and <30% in 43 (29.9%); PaP score was unavailable for 7 (4.9%). Median ESAS total score was 27 (IQR 20–42). By PERSONS assessment, at least one target symptom (intensity ≥7/10) was present in 80 patients (55.6%). The most frequent targets were dyspnea (55/144, 38.2%), rehabilitation needs (35/144, 24.3%), suffering/distress (30/144, 20.8%), sleep disturbance (18/144, 12.5%), pain (19/144, 13.2%), eating difficulties (16/144, 11.1%), and nausea (2/144, 1.4%). Palliative (terminal) sedation was required in 37/144 patients (25.7%). Among sedated patients, the most common refractory indications were dyspnea (22/37, 59.4%), agitation (21/37, 56.7%), pain (5/37, 13.5%), and delirium/psychosis (5/37, 13.5%); median duration of sedation was 36 hours (IQR 24-72). Overall, 101 patients (70.1%) died in the PC Ward, while 43 (29.9%) were discharged home or to other healthcare facilities. Table 2 . Hospitalization features of patients admitted to the Palliative Care Ward Characteristics Patients n= 144, (%) Home-based palliative care prior to admission Yes No 39 (27.1) 105 (72.9) Provenance Home/other healthcare facility Oncological Medicine ward Oncology ward Internal Medicine ward Emergency Clinic Other 32 (22.2) 43 (29.9) 23 (16.0) 28 (19.4) 6 (4.2) 12 (8.3) Symptoms at admission Dyspnea Pain Neurologic symptoms Global clinical deterioration Gastrointestinal symptoms Jaundice 43 (29.9) 35 (24.3) 28 (19.4) 23 (16.0) 5 (3.5) 2 (1.4) PaP risk category (30-day mortality) >70% 30-70% <30% Not available 37 (25.7) 57 (39.6) 43 (29.9) 7 (4.9) ESAS total score , median (IQR) 27 (20-42) PERSONS: ≥1 target symptom (≥7/10) Yes No 80 (55.6) 64 (44.4) Palliative (terminal) Sedation, median duration (hours, IQR) Yes No 36 (24-72) 37 (25.7) 107 (74.3) Refractory symptom Dyspnea Agitation Pain Psychosis 22 (59.4)* 21 (56.7)* 5 (13.5)* 5 (13.5)* Discharge to home-based palliative care Yes No 43 (29.9) 101 (70.1) *Percentages calculated among the 37 patients who received palliative sedation (multiple indications allowed) 3.3 Clinical outcomes The median interval from the first oncologic visit to PC Ward admission was 4.1 months (95% CI, 0.8-12.7), and from diagnosis to PC Ward admission was 4.8 months (95% CI, 1.1-11.7) ( Table 3 ). The median time from last anticancer therapy to admission was 24 days (95% CI, 15-44); 52 patients (36.1%) had received systemic treatment within 30 days prior to admission. Among the 43 patients discharged to home-based PC, the median length of the index hospitalization was 13 days (95% CI, 5-35). By the data cutoff, 143/144 patients (99.3%) had died. Median OS from PC Ward admission was 14 days (95% CI, 10-18) ( Figure 2 ). OS differed markedly by discharge status: patients who were discharged had longer survival than those who remained in the PC Ward (median 45 vs 8 days; HR 0.12, 95% CI, 0.07-0.20; p<0.001), consistent in both univariable and multivariable analyses ( Table 4 ). Worse performance status was associated with shorter OS: ECOG ≥3 vs ECOG 2 (median 10 vs 20 days; HR 1.61, 95% CI, 1.02-2.54; p=0.04), again concordant across univariable and multivariable models ( Figure 3 ). Female sex was associated with a modest OS advantage in the multivariable model (median 15 vs 13 days; HR 0.64, 95% CI, 0.45-0.90; p=0.01) but not in univariable analysis. Younger age (<75 vs ≥75 years) showed a trend toward shorter OS in univariable analysis (median 9 vs 17.5 days; HR 1.37, 95% CI, 0.99-1.91; p=0.06) that was not retained after adjustment. No other prespecified clinical variables demonstrated statistically significant associations with mortality risk in univariable testing ( Table 4 ). Regarding discharge likelihood, Fisher’s exact tests showed no significant associations for most variables, except that presence of ≥1 target symptom on PERSONS and ECOG PS 4 correlated with a lower probability of discharge to home-based PC ( Table 5 ). Table 3. Clinical outcomes of the population and time-to-event intervals Interval median, 95% CI OS (days) 14 (10-18) first oncology consultation – admission (months) 4.1 (0.8-12.7) diagnosis – admission (months) 4.8 (1.1-11.7) Last oncology therapy – admission (days) 24 (15-44) admission – discharge (days) 13 (5-35) Table 4 . Univariable and Multivariable analysis for OS in the entire population p-values were derived by Cox regression models OS- univariable OS- multivariable HR (95% CI) p-value HR (95% CI) p-value Age <75 vs ≥75 1.37 (0.99-1.91) 0.06 1.28 (0.86-1.90) 0.21 Sex Female vs Male 0.89 (0.64-1.24) 0.5 0.63 (0.43-0.94) 0.02 ECOG PS 3-4 vs 2 1.61 (1.02-2.54) 0.04 1.86 (1.07-3.24) 0.03 Discharged to home-based PC Yes vs No 0.11 (0.07-0.20) <0.001 0.09 (0.04-0.17) <0.001 Dyspnea Yes vs No 0.96 (0.68-1.35) 0.83 0.72 (0.41-1.28) 0.27 Pain Yes vs No 0.84 (0.57-1.25) 0.39 1.02 (0.62-1.68) 0.94 Neurologic symptoms Yes vs No 0.98 (0.64-1.49) 0.92 0.64 (0.35-1.18) 0.16 Gastrointestinal symptoms Yes vs No 1.08 (0.44-2.65) 0.87 0.92 (0.26-3.22) 0.90 Clinical deterioration Yes vs No 0.82 (0.52-1.30) 0.40 0.75 (0.37-1.53) 0.44 ADI activated Yes vs No 1.06 (0.73-1-53) 0.76 0.83 (0.55-1.25) 0.37 PERSONS ≥1 target symptom (≥7/10) Yes vs No 1.42 (1.02-1.99) 0.04 0.96 (0.64-1.44) 0.84 Table 5 . Clinical features of patients according to discharge from Palliative Care Ward p-values were derived by Fisher’s exact test Characteristics Discharged n= 43, n (%) Deceased n= 101, n (%) P value Age ≥75 <75 28 (65.1) 15 (34.9) 48 (47.5) 53 (52.5) 0.07 Sex Male Female 27 (62.8) 16 (37.2) 56 (55.4) 45 (44.6) 0.46 ECOG PS 2 3 4 11 (25.6) 25 (58.1) 7 (16.3) 12 (11.9) 56 (55.4) 33 (32.7) 0.04 Histology NSCLC SCLC Mesothelioma Other No diagnosis 30 (69.8) 5 (11.6) 1 (2.3) 1 (2.3) 6 (14.0) 67 (66.3) 17 (16.8) 2 (2.0) 4 (4.0) 11 (10.9) 0.91 Symptoms at admission Dyspnea Pain Neurologic symptoms Gastrointestinal symptoms Clinical deterioration 20 (55.6) 12 (35.3) 5 (16.1) 2 (6.2) 8 (20.5) 52 (52.0) 22 (64.7) 23 (24.2) 3 (3.2) 15 (15.6) 0.84 0.26 0.46 0.60 0.61 Home-based palliative care prior to admission Yes No 12 (27.9) 31 (72.1) 74 (73.3) 27 (26.7) 1 PaP risk category (30-day mortality) ≥70% 30-70% <30% 7 (17.9) 20 (51.3) 12 (30.8) 30 (30.6) 37 (37.8) 31 (31.6) 0.24 PERSONS, target symptom Yes No 17 (39.5) 26 (60.5) 63 (62.4) 38 (37.6) 0.02 4. Discussion PC is typically delivered across three settings: home care, hospice, and hospital, but dedicated inpatient PC wards remain uncommon [ 5 ]. Most hospital programs operate in outpatient setting or as consult services rather than units with their own beds. Our experience adds to the limited literature on hospital-based PC wards designed for time-limited, high-intensity symptom control and coordinated transitions of care. In a consecutive cohort of 144 patients with advanced thoracic malignancies, we observed late engagement with PC services, substantial symptom burden at admission, frequent need for palliative sedation, and a meaningful proportion of patients discharged after clinical stabilization. Nearly three quarters of patients (72.9%) had no home-based PC in place before admission, and 36.1% had received systemic therapy within 30 days of admission, signals of late referral and transition to supportive care only after disease-directed options were discontinued. This pattern mirrors well-described barriers, including misconception associating PC solely with end of life, oncologists’ concern about “giving up”, and structural hurdles that delay referral [ 6 , 7 , 8 ]. Early PC is known to improve symptoms, communication, and care alignment [ 9 , 10 ]; our data suggest many patients with thoracic malignancies still miss this window. Our findings should be viewed within the evolving end-of-life oncology landscape. In a population-based cohort of over 68.000 patients, Iqbal et al. showed rising use of systemic anticancer therapy in the last 30 days of life, mainly driven by immunotherapy, and its association with greater health-care utilization and higher odds of hospital death [ 11 ]. In this context, a discharge-oriented inpatient PC model like ours may help counter crisis-driven admissions linked to late systemic anticancer treatments by enabling rapid symptom control and coordinated transitions. Embedding trigger-based referrals and earlier goals-of-care discussions could reduce end-of-life systemic anticancer treatment exposure and shift care toward home or hospice, when aligned with patient preferences. The ward’s direct-admission pathways from acute services and oncology clinics, its proximity to referring teams, and access to diagnostics and procedures allowed rapid titration of therapies for dyspnea, pain, agitation, and delirium. Although in-hospital death was common (70.1%), 29.9% patients were discharged home or to other facilities after stabilization, consistent with an acute, problem-solving model rather than medium- or long-stay care. Discharge correlated with better PS and absence of ≥ 1 target symptom on PERSONS at admission, and discharged patients had markedly longer OS (median 46 vs 8 days; HR 0.12), reflecting lower disease burden and demonstrating that targeted inpatient PC can serve as a bridge back to community care when triggered early enough. PERSONS screening identified dyspnea as the leading target symptom (38.2%), followed by rehabilitation needs and distress, aligning with reasons for admission and underscoring the multidimensional nature of suffering in thoracic cancers. Routine use of PERSONS and ESAS on admission made priorities explicit and informed both pharmacologic and non-pharmacologic plans. Embedding brief symptom screens upstream, both in oncology clinics and emergency settings, may flag candidates for early PC or fast-track admission to the PC ward before crises escalate. Palliative (terminal) sedation was initiated in 25.7%, most often for refractory dyspnea and agitation. Rates vary across settings and are typically higher in hospitals than at home, likely reflecting selection of patients with greater acuity [ 12 ]. Standardized indications, documentation of refractoriness, and shared decision-making with families were integral to our practice and may help harmonize use across services. Other studies have investigated trends among different countries and settings in the interval between the first PC consultation and death, to explore the adequacy of PC provision. In a systematic review, the median interval from initiation of PC to death was 18.9 days, with significant differences observed according to the presence of oncologic versus non-oncologic conditions, the type of PC service provided and the socioeconomic development level of the country [ 13 ]. Focusing on cancer patients, in a study the median time from PC referral to death was 1.9 months [ 14 ]. Another study reported a median time of 42 days between first PC consultation and death. This study also observed that patients with solid tumors, younger individuals, and female patients were more likely to access palliative care earlier [ 15 ]. The interval between cancer diagnosis and death was 32.2 months in the first study and 47.5 months in the second. Our admission routes (predominantly transfers from other wards), leading reasons for admission (dyspnea, pain), length of stay (median 13 days among those discharged), and in-unit mortality (~ 70%) are broadly consistent with prior descriptions of Italian hospital-based wards and territorial hospices, though our thoracic-only case mix likely explains the prominence of dyspnea over pain as a trigger for admission [ 5 , 16 ]. These convergences support the external credibility of our model while highlighting disease-specific nuances. This was a single-center, retrospective study without a parallel cohort managed exclusively at home or hospice, limiting causal inference and generalizability. Some variables (e.g., PaP score in 4.9%) were missing, and we lacked systematic follow-up of post-discharge symptom trajectories and caregiver outcomes. Selection bias is possible, as more complex or rapidly deteriorating patients are preferentially admitted. Strengths include consecutive enrollment, standardized symptom/prognostic assessment at admission (ESAS, PERSONS, PaP score), and detailed capture of referral pathways, sedation indications, and disposition. Our data support several actionable steps, including trigger-based PC early referral when ECOG ≥ 3, initiation of long-term oxygen, ≥ 2 unplanned admissions/Emergency Department visits in 30 days, or ESAS/PERSONS item ≥ 7, and destigmatization by mean of joint onco-PC family meetings early in the disease course. 5. Conclusions In a thoracic oncology population with high acuity and predominantly late PC engagement, a hospital-based PC Ward delivered rapid symptom control, appropriate use of palliative sedation, and enabled nearly one-third of patients to return home or to other settings after stabilization. These findings argue for the ward’s role as a complement, not an alternative, to home and hospice services, particularly when swift, multidisciplinary intervention is needed. To improve outcomes, systems should prioritize earlier integration of PC, clearer referral triggers, and streamlined transitions from hospital to community services. Building and optimizing dedicated hospital-based PC wards within comprehensive cancer centers can enhance access, continuity, and quality of end-of-life care while supporting patients and caregivers through the most complex phases of illness. Declarations Author contribution S.B: Conceptualization, Project administration, Data Curation. Writing – original draft; R.L: Conceptualization, Validation, Data Curation, Writing – review & editing; L.T: Validation, Writing – original draft; L.S: Validation, Writing – original draft; SCB: Data Curation; MYA: Data Curation; LC: Data Curation; MP: Project administration, Validation; EC: Validation; KDE: Validation; GG: Validation; FB: Conceptualization, Validation, Writing – review & editing; MD: Conceptualization, Validation, Writing – review & editing. CF: Conceptualization, Supervision, Writing – review & editing. All authors have read and agreed to the published version of the manuscript. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Funding Open access funding provided by University of Modena and Reggio Emilia. Competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the local Ethics Board. 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Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med. 2020;18(1):368. Published 2020 Nov 26. doi:10.1186/s12916-020-01829-x Cheng WW, Willey J, Palmer JL, Zhang T, Bruera E. Interval between Palliative Care Referral and Death among Patients Treated at a Comprehensive Cancer Center. Vol 8.; 2005. doi: 10.1089/jpm.2005.8.1025 Osta BE, Palmer JL, Paraskevopoulos T, et al. Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center. J Palliat Med. 2008;11(1):51-57. doi:10.1089/jpm.2007.0103 Mercadante S, Valle A, Sabba S, et al. Pattern and characteristics of advanced cancer patients admitted to hospices in Italy. Support Care Cancer. 2013;21(4):935-939. doi:10.1007/s00520-012-1608-3 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 16 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers invited by journal 08 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 16 Nov, 2025 First submitted to journal 02 Nov, 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8013362","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":557876928,"identity":"c26f27b8-90d3-4d30-a83b-18aa0e2426ec","order_by":0,"name":"Serena Barban","email":"","orcid":"","institution":"University of Modena and Reggio Emilia","correspondingAuthor":false,"prefix":"","firstName":"Serena","middleName":"","lastName":"Barban","suffix":""},{"id":557876930,"identity":"dbfadafe-35a1-4f10-ab95-2e9f4bcdca7f","order_by":1,"name":"Rita 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16:33:23","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86071,"visible":true,"origin":"","legend":"","description":"","filename":"917b35804b8a4c3e83963aa67dd6910d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8013362/v1/ccf56a89313cd77e8b639fb0.xml"},{"id":97992433,"identity":"3acff41e-21a3-4d10-bf38-4bbc1345e0c8","added_by":"auto","created_at":"2025-12-11 14:44:17","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95336,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8013362/v1/2c8f71c823f575c74f7c75c7.html"},{"id":98424438,"identity":"9a114ab0-661f-4d88-9a1b-3173f1a4e896","added_by":"auto","created_at":"2025-12-17 16:33:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75135,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of systemic anticancer treatments received in the 30 days prior to Palliative Care Ward admission among the 52 treated patients\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8013362/v1/45c705b200d9c1c6dda0fc7e.png"},{"id":97992421,"identity":"b8bfbb0f-749d-44e5-85c6-8c8633af0e3e","added_by":"auto","created_at":"2025-12-11 14:44:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39339,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier overall survival from Palliative Care Ward admission with 95% Ci in the entire population\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8013362/v1/bd68adca93737ee7eac43659.png"},{"id":98424709,"identity":"7f697161-a571-4639-aebf-a9394f251610","added_by":"auto","created_at":"2025-12-17 16:33:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":79750,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier overall survival from Palliative Care Ward admission with 95% CI (A) stratified by discharge status (discharged vs remained in ward); (B) by ECOG PS (2 vs 3-4)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8013362/v1/54681712af07d68c37fc4896.png"},{"id":98443834,"identity":"0990ca20-5ddf-4516-94de-9c3e7dc061e3","added_by":"auto","created_at":"2025-12-17 17:14:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1285016,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8013362/v1/4abbac6c-9811-436e-a2d5-97703674db02.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hospital-Based Palliative Care for Patients with Advanced Thoracic Malignancies: A Retrospective Cohort from a Tertiary Center","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThoracic malignancies are common and confer substantial mortality and morbidity. Lung cancer, the most frequent thoracic cancer, remains the leading cause of cancer-related death worldwide despite advances in tumor biology and systemic therapies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Symptom burden is typically high from both disease and treatment effects, and many patients present with advanced-stage disease. Consequently, there is a sustained need for palliative care (PC) across the illness trajectory, not only at the end of life but also alongside active oncologic treatment to provide comprehensive supportive care. Acute symptom crises and complications often necessitate hospitalization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Yet dedicated inpatient hospital-based PC units are uncommon. PC is more frequently delivered through community hospices or home-care services, models that may be oriented toward end-of-life care and not always suited to patients requiring rapid titration of therapies, complex procedures, or multidisciplinary input. In this context, hospital-based PC wards can fill a critical gap by providing intensive symptom management, time-limited inpatient stabilization, and coordinated transitions to home or hospice.\u003c/p\u003e\u003cp\u003eWe report the experience of the Palliative Care Unit at Modena University Hospital, an inpatient ward embedded within the Oncology Center and closely integrated with the Medical Oncology wards and Day Hospital. The unit comprises 10 beds and admits patients with advanced oncologic and hematologic diseases who are not receiving active anticancer therapy. Referrals originate from other hospital wards, community services, or the Oncology Center\u0026rsquo;s emergency clinic; admission can also occur at the direct request of the treating oncologist or hematologist. Unlike many territorial hospices, which often require prior enrollment in home PC, our ward permits direct admission, thereby enabling access for patients without structured palliative support. Indications include complex symptom management, end-of-life care, palliative procedures, caregiver respite, and mitigation of social or logistical barriers to care. The ward is medically supervised and staffed by dedicated physicians, nurses, and healthcare assistants, with psychologists, physiatrists, and nutritionists available on call. On admission, all patients undergo standardized assessment using the Edmonton Symptom Assessment System (ESAS), the Palliative Prognostic (PaP) Score, and the PERSONS (Pain-Eating-Rehabilitation-Sleep-Oxygen-Nausea-Suffering) score [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The aim of the study is to describe the structure, admission pathways, and clinical role of a hospital-based PC unit in managing patients with thoracic malignancies, and to characterize patient profiles, indications for admission, and early outcomes within this care model.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003eWe conducted a single-center, retrospective, observational cohort study of consecutive adults with advanced-stage thoracic malignancies admitted to the PC Ward of the University Hospital of Modena between January 2022 and September 2024. The PC ward is an inpatient unit embedded within the Oncology Center and staffed by a dedicated multidisciplinary team. Eligible patients were \u0026ge;\u0026thinsp;18 years old with an advanced thoracic malignancy (e.g., Non-Small Cell Lung Cancer, Small Cell Lung Cancer, mesothelioma, thymic tumors) admitted to the PC ward during the study period. To avoid duplication, only the first PC-ward admission per patient was analyzed. Patients receiving active anticancer therapy at the time of admission were included; receipt of therapy within 30 days was captured as a covariate.\u003c/p\u003e\u003cp\u003eData were abstracted from the electronic medical record using a standardized case-report form and included: demographics (age, sex), disease features (histology, number and sites of metastases), clinical variables (Eastern Cooperative Oncology Group [ECOG] performance status [PS]; receipt of systemic anticancer therapy within 30 days prior to admission [yes/no; class recorded when available]; time from initial diagnosis to PC admission), and hospitalization details (referral source [other hospital wards, home, or other facilities], presence of home-care services before admission, indication for admission [e.g., dyspnea, pain], need for palliative sedation, palliative sedation indication and duration, discharge vs in-hospital death, and place of death). Symptoms prompting hospitalization were also recorded, and the ESAS score and PERSONS score were applied for their assessment. Upon admission, PaP score was also performed. All scales were administered as part of routine care at admission according to institutional procedures.\u003c/p\u003e\u003cp\u003eThe primary objective was to characterize clinical needs and hospitalization patterns among patients with advanced thoracic malignancies admitted to the PC ward, focusing on symptom burden, palliative interventions and end-of-life care. Overall survival (OS) was defined as the time from PC-ward admission to death from any cause; patients alive at last follow-up were censored on that date. Continuous variables are reported as median and interquartile range (IQR) or mean and standard deviation, as appropriate; categorical variables as counts and percentages. Group comparisons used Fisher\u0026rsquo;s exact or χ\u0026sup2; tests for categorical variables and Wilcoxon rank-sum or t-tests for continuous variables, as appropriate. Survival functions were estimated using the Kaplan\u0026ndash;Meier method and compared with the log-rank test. Hazard ratios (HRs) with 95% confidence intervals (CIs) were obtained from Cox proportional hazards models; proportional hazards assumptions were evaluated using Schoenfeld residuals. All tests were two-sided with α\u0026thinsp;=\u0026thinsp;0.05. Analyses were performed in R (version 4.0.3; 2020-10-10). The extent of missingness for key variables was summarized; analyses used available data (complete-case). No imputation was performed. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Area Vasta Emilia Nord Ethic Committee.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cem\u003e3.1 Patients\u0026rsquo; characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe analyzed 144 consecutive patients with advanced thoracic cancers, representing 20% of all PC Ward admissions during the study period (\u003cstrong\u003eTable 1\u003c/strong\u003e). The cohort included 61 women (42.4%) and 83 men (57.6%); median age was 75 years (IQR 68-80), with 52.8% aged \u0026ge;75 years.\u003c/p\u003e\n\u003cp\u003eNon\u0026ndash;small cell lung cancer (NSCLC) was the most common diagnosis (97/144, 67.4%), followed by small cell lung cancer (SCLC; 22/144, 15.3%) and mesothelioma (3/144, 2.1%); five patients (3.5%) had other histologies. In 17 patients (11.8%), a histologic diagnosis could not be obtained due to clinical instability. All patients had stage IV disease, with a median of 3 metastatic sites per patient. Common metastatic sites included lymph nodes (61.8%), bone (49.3%), liver (36.1%), lung (29.2%), brain (27.1%), and adrenal glands (22.2%); pleural involvement was recorded in 2.1%, and other sites in 21.5%.\u003c/p\u003e\n\u003cp\u003eWithin 30 days prior to PC-ward admission, 52 patients (36.1%) received systemic anticancer therapy: chemotherapy in 23 (44.2%), chemo-immunotherapy in 8 (15.4%), immunotherapy in 14 (26.9%), targeted therapy in 6 (11.6%), and other treatments in 1 (1.9%) (\u003cstrong\u003eFigure 1\u003c/strong\u003e). Radiotherapy was delivered to 28 patients (19.4%) overall: eight (5.6%) in combination with systemic therapy and 20 (13.9%) without systemic therapy in the same timeframe.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Baseline characteristics of patients admitted to the Palliative Care Unit\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"473\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cem\u003eCharacteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003ePatients\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en= 144, (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge,\u0026nbsp;\u003c/strong\u003emedian (IQR), years\u003c/p\u003e\n \u003cp\u003e\u0026ge;75\u003c/p\u003e\n \u003cp\u003e\u0026lt;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e75 (68-80)\u003c/p\u003e\n \u003cp\u003e76 (52.8)\u003c/p\u003e\n \u003cp\u003e68 (47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e83 (57.6)\u003c/p\u003e\n \u003cp\u003e61 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eECOG PS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23 (16.0)\u003c/p\u003e\n \u003cp\u003e81 (56.2)\u003c/p\u003e\n \u003cp\u003e40 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistology\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNSCLC\u003c/p\u003e\n \u003cp\u003eSCLC\u003c/p\u003e\n \u003cp\u003eMesothelioma\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003cp\u003eNo diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97 (67.4)\u003c/p\u003e\n \u003cp\u003e22 (15.3)\u003c/p\u003e\n \u003cp\u003e3 (2.1)\u003c/p\u003e\n \u003cp\u003e5 (3.5)\u003c/p\u003e\n \u003cp\u003e17 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMetastatic sites\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003cp\u003eLymph nodes\u003c/p\u003e\n \u003cp\u003ePleura\u003c/p\u003e\n \u003cp\u003eLiver\u003c/p\u003e\n \u003cp\u003eBone\u003c/p\u003e\n \u003cp\u003eBrain\u003c/p\u003e\n \u003cp\u003eAdrenal gland\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42 (29.2)\u003c/p\u003e\n \u003cp\u003e89 (61.8)\u003c/p\u003e\n \u003cp\u003e3 (2.1)\u003c/p\u003e\n \u003cp\u003e52 (36.1)\u003c/p\u003e\n \u003cp\u003e71 (49.3)\u003c/p\u003e\n \u003cp\u003e39 (27.1)\u003c/p\u003e\n \u003cp\u003e32 (22.2)\u003c/p\u003e\n \u003cp\u003e31 (21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystemic anticancer treatment \u0026lt;30 days\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003cp\u003eChemo-immunotherapy\u003c/p\u003e\n \u003cp\u003eImmunotherapy\u003c/p\u003e\n \u003cp\u003eTargeted therapy\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e52 (36.1)\u003c/p\u003e\n \u003cp\u003e23 (44.2)*\u003c/p\u003e\n \u003cp\u003e8 (15.4)*\u003c/p\u003e\n \u003cp\u003e14 (26.9)*\u003c/p\u003e\n \u003cp\u003e6 (11.6)*\u003c/p\u003e\n \u003cp\u003e1 (1.9)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiotherapy \u0026lt;30 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e20 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystemic treatment + radiotherapy \u0026lt;30 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e8 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e*% calculated on a total of 52 patients who received anticancer treatment in the last 30 days\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2 Hospitalization characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost patients (112/144, 77.8%) were transferred to the PC Ward from other hospital services, while 32 (22.2%) were admitted directly from home or residential facilities (\u003cstrong\u003eTable 2\u003c/strong\u003e). Transfers originated mainly from the Oncological Medicine ward (43/144, 29.9%), the Oncology ward (23/144, 16.0%), and Internal Medicine ward (28/144, 19.4%); an additional 12 patients (8.3%) were transferred from other departments, and 6 (4.2%) were admitted directly from the Oncology Center emergency clinic.\u003c/p\u003e\n\u003cp\u003eBefore hospitalization, most patients were not enrolled in home-based PC (105/144, 72.9%). The leading indications for PC Ward admission were dyspnea (43/144, 29.9%), pain (35/144, 24.3%), neurologic symptoms (28/144, 19.4%), and global clinical deterioration (23/144, 16.0%); gastrointestinal symptoms (5/144, 3.5%) and jaundice (2/144, 1.4%) were less frequent.\u003c/p\u003e\n\u003cp\u003eAt admission, PaP score indicated a \u0026gt;70% 30-day mortality risk in 37 patients (25.7%), 30-70% in 57 (39.6%), and \u0026lt;30% in 43 (29.9%); PaP score was unavailable for 7 (4.9%). Median ESAS total score was 27 (IQR 20\u0026ndash;42). By PERSONS assessment, at least one \u003cstrong\u003etarget symptom\u003c/strong\u003e (intensity \u0026ge;7/10) was present in 80 patients (55.6%). The most frequent targets were dyspnea (55/144, 38.2%), rehabilitation needs (35/144, 24.3%), suffering/distress (30/144, 20.8%), sleep disturbance (18/144, 12.5%), pain (19/144, 13.2%), eating difficulties (16/144, 11.1%), and nausea (2/144, 1.4%).\u003c/p\u003e\n\u003cp\u003ePalliative (terminal) sedation was required in 37/144 patients (25.7%). Among sedated patients, the most common refractory indications were dyspnea (22/37, 59.4%), agitation (21/37, 56.7%), pain (5/37, 13.5%), and delirium/psychosis (5/37, 13.5%); median duration of sedation was 36 hours (IQR 24-72). Overall, 101 patients (70.1%) died in the PC Ward, while 43 (29.9%) were discharged home or to other healthcare facilities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Hospitalization features of patients admitted to the Palliative Care Ward\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"482\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cem\u003eCharacteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cem\u003ePatients\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en= 144, (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome-based palliative care prior to admission\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39 (27.1)\u003c/p\u003e\n \u003cp\u003e105 (72.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvenance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHome/other healthcare facility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOncological Medicine ward\u003c/p\u003e\n \u003cp\u003eOncology ward\u003c/p\u003e\n \u003cp\u003eInternal Medicine ward\u003c/p\u003e\n \u003cp\u003eEmergency Clinic\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (22.2)\u003c/p\u003e\n \u003cp\u003e43 (29.9)\u003c/p\u003e\n \u003cp\u003e23 (16.0)\u003c/p\u003e\n \u003cp\u003e28 (19.4)\u003c/p\u003e\n \u003cp\u003e6 (4.2)\u003c/p\u003e\n \u003cp\u003e12 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms at admission\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDyspnea\u003c/p\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003cp\u003eNeurologic symptoms\u003c/p\u003e\n \u003cp\u003eGlobal clinical deterioration\u003c/p\u003e\n \u003cp\u003eGastrointestinal symptoms\u003c/p\u003e\n \u003cp\u003eJaundice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43 (29.9)\u003c/p\u003e\n \u003cp\u003e35 (24.3)\u003c/p\u003e\n \u003cp\u003e28 (19.4)\u003c/p\u003e\n \u003cp\u003e23 (16.0)\u003c/p\u003e\n \u003cp\u003e5 (3.5)\u003c/p\u003e\n \u003cp\u003e2 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaP risk category (30-day mortality)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026gt;70%\u003c/p\u003e\n \u003cp\u003e30-70%\u003c/p\u003e\n \u003cp\u003e\u0026lt;30%\u003c/p\u003e\n \u003cp\u003eNot available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (25.7)\u003c/p\u003e\n \u003cp\u003e57 (39.6)\u003c/p\u003e\n \u003cp\u003e43 (29.9)\u003c/p\u003e\n \u003cp\u003e7 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESAS total score\u003c/strong\u003e, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e27 (20-42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePERSONS: \u0026ge;1 target symptom (\u0026ge;7/10)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e80 (55.6)\u003c/p\u003e\n \u003cp\u003e64 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePalliative (terminal) Sedation,\u0026nbsp;\u003c/strong\u003emedian duration (hours, IQR)\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e36 (24-72)\u003c/p\u003e\n \u003cp\u003e37 (25.7)\u003c/p\u003e\n \u003cp\u003e107 (74.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRefractory symptom\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDyspnea\u003c/p\u003e\n \u003cp\u003eAgitation\u003c/p\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (59.4)*\u003c/p\u003e\n \u003cp\u003e21 (56.7)*\u003c/p\u003e\n \u003cp\u003e5 (13.5)*\u003c/p\u003e\n \u003cp\u003e5 (13.5)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarge to home-based palliative care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43 (29.9)\u003c/p\u003e\n \u003cp\u003e101 (70.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e*Percentages calculated among the 37 patients who received palliative sedation (multiple indications allowed)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3 Clinical outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe median interval from the \u003cstrong\u003efirst oncologic visit\u003c/strong\u003e to PC Ward admission was 4.1 months (95% CI, 0.8-12.7), and from \u003cstrong\u003ediagnosis\u003c/strong\u003e to PC Ward admission was 4.8 months (95% CI, 1.1-11.7) (\u003cstrong\u003eTable 3\u003c/strong\u003e). The median time from \u003cstrong\u003elast anticancer therapy\u003c/strong\u003e to admission was 24 days (95% CI, 15-44); 52 patients (36.1%) had received systemic treatment within 30 days prior to admission.\u003c/p\u003e\n\u003cp\u003eAmong the 43 patients discharged to home-based PC, the median length of the index hospitalization was 13 days (95% CI, 5-35). By the data cutoff, 143/144 patients (99.3%) had died. Median OS from PC Ward admission was 14 days (95% CI, 10-18) (\u003cstrong\u003eFigure 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eOS differed markedly by discharge status: patients who were discharged had longer survival than those who remained in the PC Ward (median 45 vs 8 days; HR 0.12, 95% CI, 0.07-0.20; p\u0026lt;0.001), consistent in both univariable and multivariable analyses (\u003cstrong\u003eTable 4\u003c/strong\u003e). Worse performance status was associated with shorter OS: ECOG \u0026ge;3 vs ECOG 2 (median 10 vs 20 days; HR 1.61, 95% CI, 1.02-2.54; p=0.04), again concordant across univariable and multivariable models (\u003cstrong\u003eFigure 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eFemale sex was associated with a modest OS advantage in the multivariable model (median 15 vs 13 days; HR 0.64, 95% CI, 0.45-0.90; p=0.01) but not in univariable analysis. Younger age (\u0026lt;75 vs \u0026ge;75 years) showed a trend toward shorter OS in univariable analysis (median 9 vs 17.5 days; HR 1.37, 95% CI, 0.99-1.91; p=0.06) that was not retained after adjustment. No other prespecified clinical variables demonstrated statistically significant associations with mortality risk in univariable testing (\u003cstrong\u003eTable 4\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eRegarding discharge likelihood, Fisher\u0026rsquo;s exact tests showed no significant associations for most variables, except that \u003cstrong\u003epresence of \u0026ge;1 target symptom on\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePERSONS\u003c/strong\u003e and \u003cstrong\u003eECOG PS 4\u003c/strong\u003e correlated with a lower probability of discharge to home-based PC (\u003cstrong\u003eTable 5\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eClinical outcomes of the population and time-to-event intervals\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"444\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003e\u003cem\u003eInterval\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cem\u003emedian, 95% CI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eOS (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e14 (10-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003efirst oncology consultation \u0026ndash; admission (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e4.1 (0.8-12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003ediagnosis \u0026ndash; admission (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e4.8 (1.1-11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eLast oncology therapy \u0026ndash; admission (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e24 (15-44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 333px;\"\u003e\n \u003cp\u003eadmission \u0026ndash; discharge (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e13 (5-35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Univariable and Multivariable analysis for OS in the entire population \u003cem\u003ep-values were derived by Cox regression models\u003c/em\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 332px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOS- univariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOS- multivariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eHR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026lt;75 vs\u0026nbsp;\u0026ge;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1.37 (0.99-1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.28 (0.86-1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eFemale vs Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.89 (0.64-1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.63 (0.43-0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eECOG PS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e3-4 vs 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1.61 (1.02-2.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.86 (1.07-3.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarged to home-based PC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.11 (0.07-0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.09 (0.04-0.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDyspnea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.96 (0.68-1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.72 (0.41-1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.84 (0.57-1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.02 (0.62-1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeurologic symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.98 (0.64-1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.64 (0.35-1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrointestinal symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1.08 (0.44-2.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.92 (0.26-3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical deterioration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.82 (0.52-1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.75 (0.37-1.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eADI activated\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1.06 (0.73-1-53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.83 (0.55-1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePERSONS \u0026ge;1 target symptom (\u0026ge;7/10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eYes vs No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1.42 (1.02-1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.96 (0.64-1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e. Clinical features of patients according to discharge from Palliative Care Ward \u003cem\u003ep-values were derived by Fisher\u0026rsquo;s exact test\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cem\u003eCharacteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cem\u003eDischarged\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en= 43, n (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cem\u003eDeceased\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en= 101, n (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ge;75\u003c/p\u003e\n \u003cp\u003e\u0026lt;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (65.1)\u003c/p\u003e\n \u003cp\u003e15 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48 (47.5)\u003c/p\u003e\n \u003cp\u003e53 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (62.8)\u003c/p\u003e\n \u003cp\u003e16 (37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e56 (55.4)\u003c/p\u003e\n \u003cp\u003e45 (44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eECOG PS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (25.6)\u003c/p\u003e\n \u003cp\u003e25 (58.1)\u003c/p\u003e\n \u003cp\u003e7 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (11.9)\u003c/p\u003e\n \u003cp\u003e56 (55.4)\u003c/p\u003e\n \u003cp\u003e33 (32.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistology\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNSCLC\u003c/p\u003e\n \u003cp\u003eSCLC\u003c/p\u003e\n \u003cp\u003eMesothelioma\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003cp\u003eNo diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (69.8)\u003c/p\u003e\n \u003cp\u003e5 (11.6)\u003c/p\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003cp\u003e6 (14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67 (66.3)\u003c/p\u003e\n \u003cp\u003e17 (16.8)\u003c/p\u003e\n \u003cp\u003e2 (2.0)\u003c/p\u003e\n \u003cp\u003e4 (4.0)\u003c/p\u003e\n \u003cp\u003e11 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms at admission\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDyspnea\u003c/p\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003cp\u003eNeurologic symptoms\u003c/p\u003e\n \u003cp\u003eGastrointestinal symptoms\u003c/p\u003e\n \u003cp\u003eClinical deterioration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (55.6)\u003c/p\u003e\n \u003cp\u003e12 (35.3)\u003c/p\u003e\n \u003cp\u003e5 (16.1)\u003c/p\u003e\n \u003cp\u003e2 (6.2)\u003c/p\u003e\n \u003cp\u003e8 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52 (52.0)\u003c/p\u003e\n \u003cp\u003e22 (64.7)\u003c/p\u003e\n \u003cp\u003e23 (24.2)\u003c/p\u003e\n \u003cp\u003e3 (3.2)\u003c/p\u003e\n \u003cp\u003e15 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome-based palliative care prior to admission\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (27.9)\u003c/p\u003e\n \u003cp\u003e31 (72.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e74 (73.3)\u003c/p\u003e\n \u003cp\u003e27 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaP risk category (30-day mortality)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ge;70%\u003c/p\u003e\n \u003cp\u003e30-70%\u003c/p\u003e\n \u003cp\u003e\u0026lt;30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (17.9)\u003c/p\u003e\n \u003cp\u003e20 (51.3)\u003c/p\u003e\n \u003cp\u003e12 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (30.6)\u003c/p\u003e\n \u003cp\u003e37 (37.8)\u003c/p\u003e\n \u003cp\u003e31 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePERSONS, target symptom\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (39.5)\u003c/p\u003e\n \u003cp\u003e26 (60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63 (62.4)\u003c/p\u003e\n \u003cp\u003e38 (37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003ePC is typically delivered across three settings: home care, hospice, and hospital, but dedicated inpatient PC wards remain uncommon [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Most hospital programs operate in outpatient setting or as consult services rather than units with their own beds. Our experience adds to the limited literature on hospital-based PC wards designed for time-limited, high-intensity symptom control and coordinated transitions of care. In a consecutive cohort of 144 patients with advanced thoracic malignancies, we observed late engagement with PC services, substantial symptom burden at admission, frequent need for palliative sedation, and a meaningful proportion of patients discharged after clinical stabilization.\u003c/p\u003e\u003cp\u003eNearly three quarters of patients (72.9%) had no home-based PC in place before admission, and 36.1% had received systemic therapy within 30 days of admission, signals of late referral and transition to supportive care only after disease-directed options were discontinued. This pattern mirrors well-described barriers, including misconception associating PC solely with end of life, oncologists\u0026rsquo; concern about \u0026ldquo;giving up\u0026rdquo;, and structural hurdles that delay referral [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Early PC is known to improve symptoms, communication, and care alignment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; our data suggest many patients with thoracic malignancies still miss this window.\u003c/p\u003e\u003cp\u003eOur findings should be viewed within the evolving end-of-life oncology landscape. In a population-based cohort of over 68.000 patients, Iqbal et al. showed rising use of systemic anticancer therapy in the last 30 days of life, mainly driven by immunotherapy, and its association with greater health-care utilization and higher odds of hospital death [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this context, a discharge-oriented inpatient PC model like ours may help counter crisis-driven admissions linked to late systemic anticancer treatments by enabling rapid symptom control and coordinated transitions. Embedding trigger-based referrals and earlier goals-of-care discussions could reduce end-of-life systemic anticancer treatment exposure and shift care toward home or hospice, when aligned with patient preferences.\u003c/p\u003e\u003cp\u003eThe ward\u0026rsquo;s direct-admission pathways from acute services and oncology clinics, its proximity to referring teams, and access to diagnostics and procedures allowed rapid titration of therapies for dyspnea, pain, agitation, and delirium. Although in-hospital death was common (70.1%), 29.9% patients were discharged home or to other facilities after stabilization, consistent with an acute, problem-solving model rather than medium- or long-stay care. Discharge correlated with better PS and absence of \u0026ge;\u0026thinsp;1 target symptom on PERSONS at admission, and discharged patients had markedly longer OS (median 46 vs 8 days; HR 0.12), reflecting lower disease burden and demonstrating that targeted inpatient PC can serve as a bridge back to community care when triggered early enough.\u003c/p\u003e\u003cp\u003ePERSONS screening identified dyspnea as the leading target symptom (38.2%), followed by rehabilitation needs and distress, aligning with reasons for admission and underscoring the multidimensional nature of suffering in thoracic cancers. Routine use of PERSONS and ESAS on admission made priorities explicit and informed both pharmacologic and non-pharmacologic plans. Embedding brief symptom screens upstream, both in oncology clinics and emergency settings, may flag candidates for early PC or fast-track admission to the PC ward before crises escalate.\u003c/p\u003e\u003cp\u003ePalliative (terminal) sedation was initiated in 25.7%, most often for refractory dyspnea and agitation. Rates vary across settings and are typically higher in hospitals than at home, likely reflecting selection of patients with greater acuity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Standardized indications, documentation of refractoriness, and shared decision-making with families were integral to our practice and may help harmonize use across services.\u003c/p\u003e\u003cp\u003eOther studies have investigated trends among different countries and settings in the interval between the first PC consultation and death, to explore the adequacy of PC provision. In a systematic review, the median interval from initiation of PC to death was 18.9 days, with significant differences observed according to the presence of oncologic versus non-oncologic conditions, the type of PC service provided and the socioeconomic development level of the country [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Focusing on cancer patients, in a study the median time from PC referral to death was 1.9 months [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Another study reported a median time of 42 days between first PC consultation and death. This study also observed that patients with solid tumors, younger individuals, and female patients were more likely to access palliative care earlier [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The interval between cancer diagnosis and death was 32.2 months in the first study and 47.5 months in the second.\u003c/p\u003e\u003cp\u003eOur admission routes (predominantly transfers from other wards), leading reasons for admission (dyspnea, pain), length of stay (median 13 days among those discharged), and in-unit mortality (~\u0026thinsp;70%) are broadly consistent with prior descriptions of Italian hospital-based wards and territorial hospices, though our thoracic-only case mix likely explains the prominence of dyspnea over pain as a trigger for admission [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These convergences support the external credibility of our model while highlighting disease-specific nuances.\u003c/p\u003e\u003cp\u003eThis was a single-center, retrospective study without a parallel cohort managed exclusively at home or hospice, limiting causal inference and generalizability. Some variables (e.g., PaP score in 4.9%) were missing, and we lacked systematic follow-up of post-discharge symptom trajectories and caregiver outcomes. Selection bias is possible, as more complex or rapidly deteriorating patients are preferentially admitted. Strengths include consecutive enrollment, standardized symptom/prognostic assessment at admission (ESAS, PERSONS, PaP score), and detailed capture of referral pathways, sedation indications, and disposition.\u003c/p\u003e\u003cp\u003eOur data support several actionable steps, including trigger-based PC early referral when ECOG\u0026thinsp;\u0026ge;\u0026thinsp;3, initiation of long-term oxygen, \u0026ge;\u0026thinsp;2 unplanned admissions/Emergency Department visits in 30 days, or ESAS/PERSONS item\u0026thinsp;\u0026ge;\u0026thinsp;7, and destigmatization by mean of joint onco-PC family meetings early in the disease course.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn a thoracic oncology population with high acuity and predominantly late PC engagement, a hospital-based PC Ward delivered rapid symptom control, appropriate use of palliative sedation, and enabled nearly one-third of patients to return home or to other settings after stabilization. These findings argue for the ward\u0026rsquo;s role as a complement, not an alternative, to home and hospice services, particularly when swift, multidisciplinary intervention is needed. To improve outcomes, systems should prioritize earlier integration of PC, clearer referral triggers, and streamlined transitions from hospital to community services. Building and optimizing dedicated hospital-based PC wards within comprehensive cancer centers can enhance access, continuity, and quality of end-of-life care while supporting patients and caregivers through the most complex phases of illness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.B: Conceptualization, Project administration, Data Curation. Writing \u0026ndash; original draft; R.L: Conceptualization, Validation, Data Curation, Writing \u0026ndash; review \u0026amp; editing; L.T: Validation, Writing \u0026ndash; original draft; L.S: Validation, Writing \u0026ndash; original draft; SCB: Data Curation; MYA: Data Curation; LC: Data Curation; MP: Project administration, Validation; EC: Validation; KDE: Validation; GG: Validation; FB: Conceptualization, Validation, Writing \u0026ndash; review \u0026amp; editing; MD: Conceptualization, Validation, Writing \u0026ndash; review \u0026amp; editing. CF: Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpen access funding provided by University of Modena and Reggio Emilia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the\u003c/p\u003e\n\u003cp\u003eethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the local Ethics Board. Informed consent was obtained from alive individual participants included in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229-263. doi:10.3322/caac.21834\u003c/li\u003e\n\u003cli\u003eBrooks GA, Cronin AM, Uno H, Schrag D, Keating NL, Mack JW. Intensity of Medical Interventions between Diagnosis and Death in Patients with Advanced Lung and Colorectal Cancer: A CanCORS Analysis. J Palliat Med. 2016;19(1):42-50. doi:10.1089/jpm.2015.0190\u003c/li\u003e\n\u003cli\u003eBruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7(2):6-9.\u003c/li\u003e\n\u003cli\u003eCortellini A, Porzio G, Cofini V, et al. The PERSONS score: A new tool for cancer patients\u0026apos; symptom assessment in simultaneous care and home care settings. Palliat Support Care. 2020;18(1):33-38. doi:10.1017/S1478951519000543\u003c/li\u003e\n\u003cli\u003eMercadante S, Giuliana F, Bellingardo R, Albegiani G, Di Silvestre G, Casuccio A. 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(3):2811-2819. doi:10.1007/s00520-021-06685-w\u003c/li\u003e\n\u003cli\u003eZimmermann C, Wong JL, Swami N, et al. Public knowledge and attitudes concerning palliative care. BMJ Support Palliat Care. Published online October 7, 2021. doi:10.1136/bmjspcare-2021-003340\u003c/li\u003e\n\u003cli\u003eKruser TJ, Kruser JM, Gross JP, et al. Medical oncologist perspectives on palliative care reveal physician-centered barriers to early integration. Ann Palliat Med. 2020;9(5):2800-2808. doi:10.21037/apm-20-270\u003c/li\u003e\n\u003cli\u003eHausner D, Tricou C, Mathews J, et al. Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care. Oncologist. 2021;26(4):332-340. doi:10.1002/onco.13625\u003c/li\u003e\n\u003cli\u003eTemel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678\u003c/li\u003e\n\u003cli\u003eBakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741-749. doi:10.1001/jama.2009.1198\u003c/li\u003e\n\u003cli\u003eIqbal J, Moineddin R, Quinn KL, et al. Novel Systemic Anticancer Treatments and Health Services Use at the End of Life Among Adults With Cancer. J Clin Oncol. 2025;43(30):3279-3291. doi:10.1200/JCO-24-02816\u003c/li\u003e\n\u003cli\u003eMercadante S, Porzio G, Valle A, et al. Palliative sedation in patients with advanced cancer followed at home: a systematic review. J Pain Symptom Manage. 2011;41(4):754-760. doi:10.1016/j.jpainsymman.2010.07.013\u003c/li\u003e\n\u003cli\u003eJordan RI, Allsop MJ, ElMokhallalati Y, et al. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med. 2020;18(1):368. Published 2020 Nov 26. doi:10.1186/s12916-020-01829-x\u003c/li\u003e\n\u003cli\u003eCheng WW, Willey J, Palmer JL, Zhang T, Bruera E. Interval between Palliative Care Referral and Death among Patients Treated at a Comprehensive Cancer Center. Vol 8.; 2005. doi: 10.1089/jpm.2005.8.1025\u003c/li\u003e\n\u003cli\u003eOsta BE, Palmer JL, Paraskevopoulos T, et al. Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center. J Palliat Med. 2008;11(1):51-57. doi:10.1089/jpm.2007.0103\u003c/li\u003e\n\u003cli\u003eMercadante S, Valle A, Sabba S, et al. Pattern and characteristics of advanced cancer patients admitted to hospices in Italy. Support Care Cancer. 2013;21(4):935-939. doi:10.1007/s00520-012-1608-3\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"lung cancer, thoracic malignancies, palliative care, hospital-based hospice","lastPublishedDoi":"10.21203/rs.3.rs-8013362/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8013362/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003ePatients with advanced thoracic malignancies carry heavy symptom burden and decline rapidly, yet hospital-based palliative care (PC) units are uncommon. We report outcomes of patients admitted to the University Hospital of Modena\u0026rsquo;s PC ward.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective, observational study of consecutive patients with advanced thoracic malignancies admitted to the PC ward between 2022 and 2024. Demographics, disease characteristics, most recent oncologic treatment, hospitalization details and outcomes were collected. Descriptive statistics, χ\u0026sup2; test, Cox models and Kaplan\u0026ndash;Meier were used.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWe included 144 patients (42.4% female; median age 75 years). NSCLC was the most frequent histology (68.1%), followed by SCLC (15.3%); 11.8% lacked histologic confirmation due to clinical deterioration. In the 30 days prior to admission, 36.1% received a systemic anticancer treatment and 72.9% had not received home-based PC. Most patients were transferred from other hospital wards; 22.2% were referred from home or other facilities. The median interval from diagnosis to PC admission was 4.8 months (95% CI, 1.1\u0026ndash;11.7). Median overall survival (OS) from admission was 14 days (95% CI, 10\u0026ndash;18). Palliative sedation was required in 25.7% of patients, mainly for refractory dyspnea and agitation. Overall, 29.9% were discharged after stabilization; discharge was more likely without target symptoms on PERSONS score (60.5% vs 37.6%; p\u0026thinsp;=\u0026thinsp;0.02) and was associated with longer OS (45 vs 8 days; HR 0.12; 95% CI 0.08\u0026ndash;0.21; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eA hospital-based PC ward offers symptoms management and end-of-life care despite late referrals. The inpatient setting ensures continuity of care and works as a discharge-oriented ward.\u003c/p\u003e","manuscriptTitle":"Hospital-Based Palliative Care for Patients with Advanced Thoracic Malignancies: A Retrospective Cohort from a Tertiary Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 14:44:12","doi":"10.21203/rs.3.rs-8013362/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"309313053046727049458713638025027796296","date":"2026-03-16T20:30:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132926014213389490946616940878924303239","date":"2026-03-16T12:49:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-08T20:30:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T20:26:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-16T22:51:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-11-02T22:14:06+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":"bd5ba790-e15e-4b8b-98bb-b235816598f4","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-11T14:44:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-11 14:44:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8013362","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8013362","identity":"rs-8013362","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}