The impact of early palliative care interventions on the utilization of medical care resources for end-of-life patients

The impact of early palliative care interventions on the utilization of medical care resources for end-of-life patients | 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 The impact of early palliative care interventions on the utilization of medical care resources for end-of-life patients Chia-Chia Lin, Tsing-Fen Ho, Chang-Hung Lin, Nu-Man Tsai Tsai, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3907428/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Palliative care is gaining importance, particularly with the aging population. In Taiwan, the availability of palliative care has expanded, supported by reimbursement initiatives from the Taiwan National Health Insurance. The healthcare system in Taiwan is currently integrating more comprehensive palliative care payment benefit plans. However, incorporating palliative care services into the medical care of critically ill individuals nearing the end of life presents several challenges. This study aims to examine the impact of palliative care on the utilization of medical resources in end-of-life scenarios. Methods A total of 2,202 patients were included in this study. The primary diagnosis and intervention for palliative referral and consultation were based on the HNI code. Additionally, eight dependent indicators of medical resource utilization,30 days before death, were employed in this study. Results Hospice care for end-of-life patients was associated with less medical resource and aggressive care in the 30 days before death, including intensive care unit use (odds ratio [OR] = 0.468, 95% confidence interval [CI], 0.378–0.579, P < 0.001, cardiopulmonary resuscitation ([OR] = 0.247, 95% CI: 0.154–0.394, P < 0.001, endotracheal intubation ([OR] = 0.266, 95% CI: 0.191–0.372, P < 0.001, respiratory ventilator support ([OR] = 0.431, 95% CI: 0.348–0.533, P < 0.001) and blood transfusion ([OR] = 0.819, 95% CI: 0.667–1.005, P = 0.0555). Conclusion Patients at the end-of-life who received palliative care experienced a reduced incidence of aggressive medical interventions before death. These encompassed activities such as stays in the intensive care unit, cardiopulmonary resuscitation, endotracheal intubation, respiratory ventilator support, and blood transfusions. The utilization of medical resources varies among patients based on their specific diseases and comorbidities. Early intervention of palliative care or consultation, both for cancer and chronic disease patients, tends to result in less aggressive medical care interventions, including endotracheal intubation, respiratory ventilation, or even cardiopulmonary resuscitation in patients with severe illnesses. Early palliative care interventions Medical care resources End-of-life patients Medical futility Figures Figure 1 Figure 2 Introduction Palliative care is becoming increasingly essential as the population ages, and Taiwan, in particular, is undergoing a rapid aging process, ranking among the world’s oldest populations. Projections indicate that the average life expectancies will increase from 81.8 years in 2022 to 88.1 years by 2070. By the end of 2025, nearly 20% of the population will be aged 65 or older, which is a super-aged society according to forecasts from the Taiwan National Development Council [ 1 ]. These demographic shifts position Taiwan to have one of the highest proportions of older adults by 2060. According to a WHO survey, only 50% of countries globally have reported having palliative care within their national non-communicable disease policy. Additionally, the availability of palliative care services (PCSs) remains limited for patients diagnosed with a chronic disease globally, and with only 39% of countries further reporting their general availability with regards to reaching at least 50% of patients in need in primary health care and 40% with regards to community- or home-based care [ 2 ]. Population aging has become a national crisis that not only affects the entire healthcare system but also the overall economic growth of society. Advancements in technology and medicine have led to the use of medications and life-sustaining tools to prolong life. People with terminal or incurable diseases were treated extensively, and some treatments were futile and ineffective, which could have worsened their condition. Overuse of futile medical interventions to extend life may not only be a family burden but also be counterproductive for the health care system. Palliative care is currently recognized as the best medical care model for patients nearing the end-of-life. An increasing number of countries are integrating palliative care to facilitate healthcare resource allocation as well as decrease medical waste and social burden. Furthermore, even with the advancements in science and technology, human deaths are unavoidable. PCSs are now widely acknowledged as a specialty in patient management to improve the quality of life of terminally ill patients and better manage their symptoms and disease progression. The combined care between clinical medical professionals with palliative care teams can significantly reduce conflict among professionals, patients, and their families [ 3 ]. Considering the limited medical resources available, integrating PCSs into the national health insurance (NHI) system will not only benefit improving the quality of life for patients nearing their end-of-life but also control the health insurance budget and reduce medical futility [ 4 , 5 ]. Palliative care is currently in high demand among patients in Asia, particularly in Taiwan, Japan, and China, for both cancer and non-cancer patients [ 6 ]. According to the 2021 annual report from the Ministry of Health and Welfare in Taiwan, only 62.8% of all cancer patients received such services in the year prior to their death in 2019 [ 7 ]. Palliative care in Taiwan’s healthcare system has expanded thanks to a scheme implemented by the NHI in 2009 for the reimbursement of palliative care for eight significant non-cancer terminal patients. In 2020, the bureau of Taiwan NHI started to fully support and promote several palliative care projects, including “cancer psycho-oncology healthcare training program,” “Taiwan cancer and non-cancer palliative care outcome collaboration program,” “building hospice and palliative care resources center program,” and “compassionate community program for terminal cancer patients.” These palliative care insurance plans have contributed to Taiwan’s overall improvement and comprehensiveness with regards to the quality of its healthcare system. However, patients, their families, and healthcare professionals still find it difficult to make treatment decisions and manage the utilization of medical resources even after several promotional programs and policies have been implemented. In assessing the quality of medical care at the end of life, various potential quality measures have been employed to measure the level of aggressive and palliative care available [ 8 – 10 ]. There is evidence to support the cost-effectiveness of palliative care with regards to healthcare costs and the decrease in the utilization of aggressive treatments, including ventilation, endotracheal intubation, and resuscitation [ 11 ]. Other studies have indicated that patients who receive palliative care at the end of life will have lower hospitalization rates, fewer ICU days, less active treatment, and a reduced length of hospital stay (LOS) when they receive palliative consultations within 72 hours of being admitted to the hospital [ 12 , 13 ]. Nevertheless, the availability of medical resources can vary depending on the different diseases, clinical practices, and timing of palliative care interventions. It is crucial to understand palliative care interventions and the timing of palliative consultations that patients receive before death to improve their quality of life. This study aimed to examine how healthcare resource utilization differs between patients who received palliative care and those who did not and assessed the medical resource utilization for various diseases and the timing of palliative care intervention during the final hospital admission of patients in end-of-life situations. Methods Data collection A flowchart of the enrollment process for the study cohort is exhibited in Fig. 1 . Data on the utilization of medical resources by patients who died at Taichung Tzu-Chi Hospital were retrieved from the hospital information system database from 2019 to 2021 (n = 2,454). The exclusion criteria were age < 20 years (n = 7) or death occurring within 24 hours of hospital administration (n = 245). A total of 2,202 patients were included in this study, of whom 1,364 (61.9%) received PCS nearing the end of their lives. In PCS group, 275 (20.2%) of patients received either palliative care or a palliative related consultation before their last hospital admission, and 1,089 (79.8%) received palliative care or a palliative related consultation after their last hospitalization. In Taiwan, the NHI program covers approximately 99% of residents and is a single-payer system that provides universal insurance coverage for medical services. All residents of Taiwan have free access to medical providers, such as medical centers or clinics. In this study, patients who received palliative care or a related consultation were defined as having admission claims following the NHI palliative care coding three months prior to their death. The NHI codes for palliative physician visits, family palliative consultants, and hospice care in hospitals are P4401B, 02020B, 05601B, 05602B, 05603B, 05362C, and 05364C. Health insurance prescriptions, treatment records, outpatient visits, ER visits, and hospitalization administration of medical history from one year prior to the patient’s death were included in the dataset. Patients’ primary and other diagnoses at the final hospitalization were defined and coded as causes of death according to the International Classification of Diseases, 10th Revision, Clinical Modification. The major diseases were: dementia (ICD-10-CM code: F01-F03), Alzheimer’s disease (G30-G32), stroke (I60-I69), heat failure (I50), COPD (J40-J47), diseases of the respiratory system (J00-J99), diseases of liver (K70-K77), acute kidney disease (N17), chronic kidney disease (N18-N19), trauma or bone fracture (S00-S99), sepsis (A40-A41), and cancer/neoplasms (C code). Indicators of aggressiveness of medical care Eight dependent indicators of medical care utilization 30 days before death were employed in this study. These indicators included: (1) emergency department visits, (2) hospitalization over a 14-day period, (3) hospitalization over a 30-day period, (4) number of days in the intensive care unit, (5) endotracheal intubation, (6) respiratory ventilation, (7) cardiopulmonary resuscitation (CPR), and (8) blood transfusion. To clarify the effectiveness and timing of PCSs, which included palliative referral, family palliative care consultants, and palliative care in the hospital, the researchers also grouped the palliative care patients into two subgroups: one group included patients who had received palliative care before their last hospitalization, and the other group included patients who received PCSs during their last hospitalization. Additionally, we calculated the LOS at the last hospitalization and the time after hospital admission. Statistical analysis All statistical analyses were performed by making use of the Statistical Analysis System software (version 9.3, SAS Institute Inc., Cary, NC, USA). Patient demographic trends included age, sex, disease diagnosis, LOS, and utilization of medical services. The characteristics of the study cohort were compared by using descriptive statistics. Rates for each indicator for the overall study cohort were compared across the palliative consultants, and a chi-square test with P < 0.05 was considered statistically significant. The impact of each indicator on the aggressiveness of the end-of-life care was examined by multivariate analysis. Descriptive statistics, frequency of use, percentage, mean, and standard deviation were utilized to describe the demographic characteristics of the study subjects. Different indicators were utilized as categorical variables, and multiple logistic regression was utilized to explore the impact of palliative care before death on the utilization of medical care services at the patients’ end of life. Considering that a single indicator may not effectively and completely evaluate the quality of medical care at the end of life, the indicators were calculated as a combination of components. Ethical approval Ethical approval was obtained from the Research Ethics Committee of Taichung Tzu-Chi Hospital (REC 110-71). Results Study population Table 1 summarizes the demographic characteristics of the 2,202 study participants. Both sexes including 938 (42.6%) female and 1,264 (57.4%) male participants were equally represented. The average age of patients that did not have a palliative consultant was higher (74.9 ± 14.1) than those that did (70.5 ± 14.5). The age groups from 21–40, 41–60, 61–80, and > age 80 were 2.0%, 20.3%, 44.0% and 33.7% respectively. With regard to the 1,364 patients that had a palliative consultant, 1,353 (99.2%) of patients received either palliative care or palliative related consultation 1–3 months prior to their death. The prevalence of patients with three major causes of death and comorbidities such as lung disease, cancer, and sepsis was 61.3%, 53.5%, and 27.4%, respectively, indicating that patients may have had cancer or multiple other chronic diseases. It is also possible for patients to have more than one comorbidity at the end of their lives. The average age for patients that had not received palliative care in comparison to the group that did was 74.1 ± 4.1 years old vs 70.5 ± 14.5 years old ( P < 0.001), respectively. There were significant differences in age distribution between the patients that had received palliative care and the patient group that did not ( P < 0.001). Furthermore, in the subgroup of the palliative care patients, the average age of patients that received palliative care before their last hospital admission versus patients that received palliative care after their last hospital admission was 66.3 ± 13.5 versus 71.7 ± 14.6 years old, respectively. Additionally, the data exhibited a significant difference in age distributions before and after the patients’ last hospital admission ( P < 0.001). The patients that visited the Emergency Room (ER) did not exhibit a significant difference between the two groups (73.4% in the no palliative care group vs. 70.5% in the palliative care group, P = 0.148). Compared to patients without PCS, those with PCS exhibited a reduced utilization of medical resources, including the duration of their stay in ICU (n = 552 vs. n = 439, P < 0.001), endotracheal intubation (n = 68 vs. n = 151, P < 0.001), respiratory ventilator use (n = 316 vs n = 444, P < 0.001), and CPR (n = 32 vs. n = 79, P < 0.001). Medical resource utilization The utilization rates of aggressive care for the PCS with and without groups are presented in Table 2. The number of ER visits have no differences statistically between the two groups with or without palliative care intervention. The average hospitalization length was 19.0 ± 9.1 days versus 15.8 ± 10.3 days ( P < 0.001) and the duration of the stay in ICU was 3.7 ± 6.7 days versus 5.8 ± 7.1 days ( P < 0.001) in palliative care and non-palliative care groups, respectively. However, the number of blood transfusion units increased significantly from 2.6 ± 5.1 in the PCS group to 3.4 ± 5.8 in the group without PCS. The medical resource utilization between cancer and lung disease Table 3 compares healthcare resource utilization between patients with cancer and lung disease who received palliative care before or after hospital admission. Regarding these cancer patients, 57.8% were male and 42.2% were female, and the proportions of patients aged 21–40, 41–60, 61–80, and > 80 years were 28 (2.9%), 267 (28.1%), 484 (50.9%), and 171 (18.0%), respectively. Palliative care and consultant services before the final hospitalization or in the post-hospitalization period did not differ significantly based on sex. However, with regards to age, the age of patients receiving palliative services after hospitalization is significantly older than that of patients receiving palliative services before hospitalization (66.3 ± 11.5 years old vs 71.7 ± 14.6 years old). In this study, there was a lower proportion of patients who were hospitalized for a period over 14 days (19.0 % vs 57.5%, P < 0.001) as well as those who were hospitalized for a period over 30 days (17.3% vs 18.3 %, P = 0.007) compared to the PCS group of patients who received care before and after hospital admission. However, in terms of the proportion of patients utilizing other healthcare resources, there was no significant difference between cancer patients before and after hospital admission ( P > 0.05). Among the lung disease patients, 60.7% were male and 39.3% were female, and the proportions of patients aged 21–40, 41–60, 61–80, and >80 years old were 20 (2.7%), 124 (16.9%), 323 (44.1%), and 265 (36.2%), respectively. The proportion of individuals over age 80 was higher in the cancer group. Patients with lung disease exhibited significant differences in receiving palliative care before or after hospital admission during hospitalization over a period of 14 days: 41.0% vs 64.4% ( P < 0.001), hospitalization over a period of 30 days: 13.1% vs 27.0% ( P = 0.001), ICU stay: 33.6% vs 51.0% ( P = 0.001), and use of respiratory ventilation: 24.6% vs 39.7% ( P = 0.002). Potential associated factors for receiving palliative care In the univariate logistic regression of factors associated with healthcare services utilized in patients in our study cohort, the likelihood of palliative patients stays in regular care ward over 14 days and over 30 days were (odds ratio [OR] = 1.95, 95% confidence interval [CI]: 1.62–2.35, P < 0.001) and OR = 1.46, 95% CI: 1.15–1.86, P = 0.002). Other than the duration of hospitalization, patients who received palliative care were associated with lower odds with regard to the utilization of aggressive medical care resources, including ICU (OR = 0.47, 95% CI: 0.38–0.58, P < 0.001), endotracheal tube procedures (OR = 0.27, 95% CI: 0.19–0.37, P < 0.001), respiratory ventilator use (OR = 0.43, 95% CI: 0.35–0.53, P < 0.001), CPR (OR = 0.25, 95% CI: 0.17–1.01, P < 0.001), and blood transfusion (OR = 0.82, 95% CI: 0.67–1.01, P < 0.001). However, in this study cohort, only ICR admissions (OR = 0.47, 95% CI: 0.38–0.58, P = 0.365) did not indicate a statistical significance (Figure 2A). In comparison, in the subgroups who received palliative care before and after the last hospitalization, the patients who had PCS either by referral or through a family consultant before their last hospitalization exhibited a decrease in healthcare resource utilization during the length of their hospital stay >14 days (OR = 0.40, 95% CI: 0.30–0.53, P 30 days (OR = 0.45, 95% CI: 0.29–0.69, P < 0.001), and respiratory ventilator use (OR = 0.57, 95% CI: 0.37–0.87, P = 0.009). However, in Taiwan, most patients still have a high likelihood of visiting the ER prior to hospital admission (OR = 1.82, 95% CI: 1.32–2.53, P < 0.001) even if they have been introduced to a PCS or consultant (Figure 2B). Utilization of aggressive medial resource among different diseases In a comparison between the cancer and non-cancer utilization of different medical resources, we measured the effectiveness between cancer and lung disease patients. Palliative care intervention before and after the last hospital admission was utilized as a variable. Figures 2C and 2D exhibit the palliative care intervention before and after the last hospital admission, respectively, in the cancer patient cohort. There was no statistical significance for ICU stay (OR = 0.84, 95% CI: 0.55–1.27, P = 0.403), endotracheal intubation (OR = 0.8, 95% CI: 0.35–1.71, P = 0.528), respiratory ventilator use (OR = 0.69, 95% CI: 0.43–1.11, P = 0.127), CPR (OR = 1.90, 95% CI: 0.68–5.28, P = 0.221), and blood transfusion (OR = 0.98, 95% CI: 0.72-1.32, P = 0.876). The association of palliative care intervention before the last hospital admission in lung disease patients was also associated with a shorter length of stay in the hospital >14 days, >30 days, and in the ICU (OR = 0.41, 95% CI: 0.27–0.62, P < 0.001; OR = 0.46, 95% CI: 0.26–0.83, P = 0.009; OR = 0.62, 95% CI: 0.39–0.98, P = 0.042, respectively). Additionally, respiratory ventilator use is also decreasing compared with patients receiving palliative care after hospital admission (OR = 0.56; 95% CI: 0.35–0.91, 95% CI: 0.35–0.91, P = 0.019). The utilization of an endotracheal tube, CPR, and blood transfusion did not exhibit significant differences statistically (OR = 0.54, 95% CI: 0.21–1.34, P = 0.181; OR = 1.20, 95% CI: 0.37–3.88, P = 0.756; OR = 1.14, 95% CI: 0.74–1.76, P = 0.558, respectively). Discussion All patients with life-limiting illnesses need palliative care to improve the quality of life for themselves and their families. Palliative care has been recommended as the standard of care for any patient diagnosed with advanced cancer [14-16]. In the past, the focus has primarily been on cancer patients, and palliative care has only recently gained recognition for patients with chronic and other illnesses. Multiple studies have indicated that in recent years, the use of palliative care has increased amongst non-cancer patients [17, 18]. However, palliative care has also been seen to be closely related to the utilization of medical resources. This study collected data from the end-of-life patients within an institution to investigate the utilization of palliative medical resources. The patient population in palliative care included both patients with cancer and individuals with chronic illnesses. The results revealed that using early integrated palliative care interventions can effectively reduce the utilization of medical resources. It is worth noting that palliative medical resources decreased in endotracheal intubation, respiratory ventilation, and CPR, but increased in the number of days that the patients stayed hospitalized and in the ICU with end-stage cancer. In Taiwan, the NHI covers almost 99.9% of the resident population. Even when receiving palliative care, patients who experience physical discomfort or illness may seek medical attention or hospitalization. The tendency to use medical services is influenced by factors such as actual healthcare utilization, benefits of unique healthcare plans, and specificities of the healthcare insurance system. Moreover, the presence of ERs in most local hospitals makes healthcare services very convenient for patients and helps maintain affordable healthcare costs. Almost half of accidental hospitalizations occur during visits to the ER. As a result, patients receiving PCSs may experience an impact on ER visits, LOS, ICU admission, and utilization of other healthcare resources. Previous studies have highlighted that the palliative care integration project has resulted in a significant better documentation of pain, fewer visits to the ER [19], and fewer admissions to acute care hospitals [20, 21]. However, in our study cohort, the likelihood of ER visits was higher compared to other studies. The propensity to use medical services is associated with factors such as actual health care utilization, the beneficial effect of a unique healthcare program, and the special characteristics of the medical insurance system [22]. A high percentage of patients who had ER visits in the last month before death, even in the palliative care group, has been demonstrated in our findings. Additionally, our results also indicated a secular trend of a decrease in the utilization of aggressive care, such as the use of endotracheal tubes, respiratory equipment, ICU hospitalization, CPR, and blood transfusion, in the palliative care group compared to the no palliative care group. Since 1995, cancer patients and other patients with severe illnesses have been eligible to apply for a “catastrophic illness certificate,” and certified patients are exempt from medical payments in Taiwan. Based on this, a higher proportion of cancer patients from the emergency department visit more than once in the last month of their lives [23]. The referral timing or provision of a palliative care consultant is difficult to define and investigate. During disease prognosis, patients with cancer may discuss with or consult a palliative care team. By contrast, older or severely ill patients are more likely to receive information about palliative care after a series of aggressive treatments in hospitals. The results indicate that the timing of palliative care intervention is a determining factor in the decrease of the length of the patient’s hospital stay. Moreover, early palliative care intervention also influences the decision to utilize aggressive medical care resources, such as endotracheal intubation, respiratory ventilation, or even CPR, in patients with different severe illnesses. Consequently, palliative care has been found to improve patients’ quality of life, decrease aggressive end-of-life care, and reduce medical costs. The use of aggressive care and medical resources varies between patients that experience different diseases and comorbidities. Lung disease is a major cause of morbidity and death in the older adult population, and disease prognosis may occur quickly and throughout the whole body through severe infections and jeopardize life within a few hours or days. However, introducing palliative care to patients with lung disease or severe infection before their last hospitalization, is lesser in proportion, compared to cancer patients (n = 122, 16.7% vs n = 247, 26.0%, Table 3). Patients with lung disease or infection are more likely to experience common clinical symptoms such as fever, nausea, vomiting, dyspnea, changes in consciousness, and even gastrointestinal bleeding. Older adult patients with an infectious condition also increased the number of repetitive hospital visits, prolonged hospitalization, and admissions to the intensive care unit [24]. Other JAMA study also reported that 40% of patients who died of sepsis in the hospital were eligible for palliative care, however, they were never referred to hospice care before admission to the hospital [25]. Patients with lung infection or sepsis are commonly prescribed with antibiotic therapy and must be admitted to the hospital. When patients develop severe sepsis associated with other acute or chronic diseases such as cancer, and their life expectancy is predicted to be within six months or less, palliative care integration may help reduce unnecessary treatment and provide better pain management and symptom control. Our data indicates a pattern of decreased aggressive care at the end of life in association with the length of hospitalization, ICU stay, and respiratory ventilator use in patients with lung disease who received PCSs prior to their last hospital admission. Patients with cancer who received palliative care showed reduced endotracheal intubation, respiratory ventilation, CPR, and blood transfusion compared to patients with lung disease. However, for patients with cancer, there were no significant differences in utilizing aggressive treatment in palliative care before or after hospitalization. In contrast, in patients with lung disease, there were significant differences in the LOS, ICU stay, and respiratory ventilator use. The timing of palliative care in patients with chronic illnesses remains controversial. A late referral to PCSs may extend the length of hospitalization and lead to delays in palliating patients in need. Furthermore, some patients may undergo aggressive procedures such as endotracheal intubation or respiratory ventilation before palliative care referral. In these circumstances, palliative care may not help improve the quality of life for chronic illness patients at their end of life. CPR is an important and progressive life-saving procedure for critically time-sensitive patients and those with heart failure. Resuscitation procedures were performed in approximately 1.9 ~5% of all emergency department visits [19, 26]. The statistics show that, excluding patients with chronic kidney disease and heat failure cases, those who received palliative care used life-sustaining treatments less frequently, avoided further resuscitation, and possibly reduced using ineffective medicines. Transfusions are a crucial component of aggressive and palliative medical care. For both palliative care and older adults at the end of life, transfusion aims at bringing supportive care [27]. In this study, the prevalence of transfusion in the palliative care group is lower than without palliative care group (55.9%, vs 62.8%, P < 0.001; Table 1), and the average amount of blood transfused was 2.6 ± 5.1 vs 3.4 ± 5.8 (Table 2). In fact, the severity and consequences of anemia can worsen owing to additional factors such as comorbidities, malnutrition, inadequate dietary intake, and decreased physical capabilities and organ functions. Consequently, the evaluation and criteria for blood transfusion may not applicable for palliative care populations [28]. Another issue for consideration is the availability and allocation of RBCs: a finite resource [29]. High prevalence of anemia (as high as 98%) has been observed in the ICU [28], and approximately 27.0%–62.1% with moderate to mild anemia during hospital stay in pneumonia patients [30, 31]. Patients who had blood transfusions at the end of life lived significantly longer than anemic patients who were not transfused and could survive longer (15 days vs 8 days) [32, 33]. Even though RBC transfusion only aims to directly treat a small portion of medical problems faced by patients receiving palliative care, particularly to improve the symptomatic anemia that may help to prolong their life in some situations. The overall blood transfusion rate reduces the odds of receiving palliative care. However, these rates differ depending on the patient’s medical care and disease. The government healthcare system and insurance policies also play critical roles in determining the type and quality of patients receiving medical care. Unlike other countries, NHI in Taiwan is a compulsory program that all citizens and legal residents must join. The payment system of the NHI covers almost all medical care expenses, including emergency visits, medication, dental services, dialysis, surgery, organ transplantation, hospitalization, and home-based medical care. The universal payment system makes healthcare affordable for everyone and avoids inequality and discrimination among patients with low-income or disadvantaged populations. Moreover, the government promotes and changes policies from focusing on cancer-related palliative care to non-cancer-related sickness to provide better and more comprehensive care for older adults and enhance the utilization of palliative care. Limitations This study had some limitations. It was based on the retrospective medical records of 2,202 patients who died in hospitals between 2019 and 2021. Medical records of PCSs and patient diagnoses were provided by Tzu-Chi hospital, and other home palliative care or medical care information were not included. Terminally ill patients who were admitted to the emergency department or hospitalized but died within 24 hours were excluded from this study. Additionally, the causes of death and comorbidities were based on 11 major diagnostic ICD-10 codes, which may not include other causes of death. Conclusion A conflict always exists between prolonging life and delaying death. Despite numerous advances in technological interventions and pioneering pharmacology, individuals live longer with life-threatening illnesses such as cancers and other chronic severe illnesses. There are few chances for medical professionals to snatch patients with illnesses back from the brink of death and restore some patients to a healthy life. However, when death is on a predictable trajectory of the disease, physicians and caregivers should focus on providing tranquility for patients through physical, psychological, and other appropriate support to relieve their pain and suffering. Nowadays, doctors still secularly cogitation as “life-sever” as treating patient recovered. Older adult patients with chronic illnesses often find themselves in an uncomfortable state between the thresholds of life and death. When facing the dying, not only patients and their families, but also medical professionals may undergo various stages as grief or powerless. Nowadays, doctors still secularly cogitation as “life-sever” as treating patient recovered. Older adult patients with chronic illnesses often find themselves in an uncomfortable state between the thresholds of life and death. When death becomes inevitable, patients may endure a state of medical purgatory, where they rely on life-sustaining interventions, such as tracheal ventilators or catheters extending from their abdomen or bladder, causing significant discomfort. Patients are continuously uncomfortable and experience pain when they are awake; most of the time, they may be sedated while sleeping to relieve pain. Nevertheless, medical caregivers often face an internal conflict about whether they should prolong the patient’s life as much as possible, even if it is just for a few days or weeks, to avoid being accused of failing of treat the patient, or tell the patient and their family that it is perhaps the time to “let go” and allow the patient to pass with comfort and dignity. The patient’s autonomy in making end-of-life and do not resuscitate decisions is more respected, and palliative care acceptance has been growing recently. The traditional idea of palliative care, which involves letting the patient die, is undergoing a transformation. Palliative care consulting provides more information to patients to optimize their end-of-life quality and benefits the healthcare system. An increasing number of hospitals provide palliative care in their health care, and patients can choose alternative options for themselves from painful, inhuman, and ineffective treatments. Palliative care could be a better solution to wrench distress and disagreement in medical, physical, social, and spiritual care for patients and their families, as well as medical professionals, and redeem terminally ill patients with dignity at the end of life. Abbreviations PCSs: Palliative care services; NHI: National health insurance; CPR: Cardiopulmonary resuscitation; ER: Emergency room; OR: Odds ratio; CI: Confidence interval; LOS: Length of hospital stay Declarations Acknowledgements We would like to specially thank the palliative care team members for their continuous support and understanding during this study and for improving this project. Authorship contributions C.-C.L and C.-H.L.: resources, methodology, data curation; T.-F.H.: conceptualization, formal analysis, writing—review and editing; N.-M. T.: review; Y.-H.K.: investigation, statistical analysis; J.- H.C.: conceptualization, data curation, and writing—original draft preparation. All the authors have read and agreed to the published version of the manuscript. Funding This research was supported by the ministry of education of Taiwan (PMN1122369), and the Taichung Tzu- Chi Hospital, Taichung, Taiwan (TTCRD112-27). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Availability of data and materials The author confirms that all data generated and analyzed during this study are included in this published article. The data sets analyzed during the current study contain patient medical information, they are not publicly available due to the patient protection policy of Tzu Chi Hospital. Inquiries related to the study data and protocol can be sent to the corresponding author. Ethics and patient consent The study has been approved by the Ethics Committee of the Taichung Tzu- Chi Hospital (REC 111-02). All medical records in this study are deidentified. For this study, the informed consent was waived by the research ethics committee of Taichung Tzu-Chi Hospital. Consent for publication Not applicable. Competing interests The authors declare the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. References Population Estimates and Manpower Estimates for the Republic of China (Taiwan). Department of Human Resources Development National Development Council 2023. World Health Organization. Global atlas of palliative care (2nd edition). The Worldwide Hospice Palliative Care Alliance, https://www.thewhpca.org/resources/global-atlas-on-end-of-life-care (accessed 9 July 2023). Quinn KL, Stukel T, Stall NM, Huang A, Isenberg S, Tanuseputro P, Goldman R, Cram P, Kavalieratos D, Detsky AS et al: Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study. BMJ (Clinical research ed) 2020; 370:m2257. Chang TS, Su YC, Lee CC: Determinants for aggressive end-of-life care for oral cancer patients: a population-based study in an Asian country. Medicine 2015; 94(4):e460. Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ: Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2008; 26(23):3860-3866. Lu Y, Gu Y, Yu W: Hospice and Palliative Care in China: Development and Challenges. Asia-Pacific journal of oncology nursing 2018; 5(1):26-32. Ministry of Health and Welfare RoCT: Taiwan Health and Welfare Report. 2021. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S: Identifying potential indicators of the quality of end-of-life cancer care from administrative data. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2003; 21(6):1133-1138. Barbera L, Seow H, Sutradhar R, Chu A, Burge F, Fassbender K, McGrail K, Lawson B, Liu Y, Pataky R et al: Quality Indicators of End-of-Life Care in Patients With Cancer: What Rate Is Right? Journal of oncology practice 2015; 11(3):e279-287. Patrick DL, Curtis JR, Engelberg RA, Nielsen E, McCown E: Measuring and improving the quality of dying and death. Annals of internal medicine 2003; 139(5 Pt 2):410-415. Thongprayoon C, Kaewput W, Petnak T, O'Corragain OA, Boonpheng B, Bathini T, Vallabhajosyula S, Pattharanitima P, Lertjitbanjong P, Qureshi F et al: Impact of Palliative Care Services on Treatment and Resource Utilization for Hepatorenal Syndrome in the United States. Medicines (Basel, Switzerland) 2021; 8(5). Kyeremanteng K, Gagnon LP, Thavorn K, Heyland D, D'Egidio G: The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation. Journal of intensive care medicine 2018; 33(6):346-353. Davis MP, Van Enkevort EA, Elder A, Young A, Correa Ordonez ID, Wojtowicz MJ, Ellison H, Fernandez C, Mehta Z: The Influence of Palliative Care in Hospital Length of Stay and the Timing of Consultation. The American journal of hospice & palliative care 2022; 39(12):1403-1409. Haun MW, Estel S, Rücker G, Friederich HC, Villalobos M, Thomas M, Hartmann M: Early palliative care for adults with advanced cancer. The Cochrane database of systematic reviews 2017; 6(6):Cd011129. Parikh RB, Kirch RA, Smith TJ, Temel JS: Early specialty palliative care--translating data in oncology into practice. The New England journal of medicine 2013; 369(24):2347-2351. Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA, Back AL, Kamdar M, Jacobsen J, Chittenden EH et al: Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2017; 35(8):834-841. Mounsey L, Ferres M, Eastman P: Palliative care for the patient without cancer. Australian journal of general practice 2018; 47(11):765-769. Kim S, Lee K, Kim S: Knowledge, attitude, confidence, and educational needs of palliative care in nurses caring for non-cancer patients: a cross-sectional, descriptive study. BMC palliative care 2020; 19(1):105. Lin YC, Hsu HK, Lai TS, Chiang WC, Lin SL, Chen YM, Chen CC, Chu TS: Emergency department utilization and resuscitation rate among patients receiving maintenance hemodialysis. Journal of the Formosan Medical Association = Taiwan yi zhi 2019; 118(12):1652-1660. Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito S, McIlwane J, Hillary K, Gonzalez J: Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. Journal of the American Geriatrics Society 2007; 55(7):993-1000. Hjermstad MJ, Kolflaath J, Løkken AO, Hanssen SB, Normann AP, Aass N: Are emergency admissions in palliative cancer care always necessary? Results from a descriptive study. BMJ open 2013; 3(5). van Loenen T, van den Berg MJ, Faber MJ, Westert GP: Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries. BMC health services research 2015; 15:465. Tang ST, Wu SC, Hung YN, Huang EW, Chen JS, Liu TW: Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000-2006. Annals of oncology : official journal of the European Society for Medical Oncology 2009; 20(2):343-348. Nasa P, Juneja D, Singh O: Severe sepsis and septic shock in the elderly: An overview. World journal of critical care medicine 2012; 1(1):23-30. Rhee C, Jones TM, Hamad Y, Pande A, Varon J, O'Brien C, Anderson DJ, Warren DK, Dantes RB, Epstein L et al: Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA network open 2019; 2(2):e187571. Lin CY, Lee YC: Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care - a nationwide matched-pair retrospective cohort study in Taiwan. BMC palliative care 2020; 19(1):87. Garraud O: Transfusion at the border of the "intention-to-treat", in the very aged person and in palliative care: A debate. Transfusion clinique et biologique : journal de la Societe francaise de transfusion sanguine 2021; 28(4):367-369. Thomas J, Jensen L, Nahirniak S, Gibney RT: Anemia and blood transfusion practices in the critically ill: a prospective cohort review. Heart & lung : the journal of critical care 2010; 39(3):217-225. Raval JS, Cooling LL: Red blood cell transfusion in palliative care: what are we doing and why are we doing it? Transfusion 2018; 58(1):3-4. Reade MC, Weissfeld L, Angus DC, Kellum JA, Milbrandt EB: The prevalence of anemia and its association with 90-day mortality in hospitalized community-acquired pneumonia. BMC pulmonary medicine 2010; 10:15. Czempik PF, Wilczek D, Herzyk J, Krzych Ł J: Hospital-Acquired Anemia in Patients Hospitalized in the Intensive Care Unit: A Retrospective Cohort Study. Journal of clinical medicine 2022; 11(14). Goksu SS, Gunduz S, Unal D, Uysal M, Arslan D, Tatli AM, Bozcuk H, Ozdogan M, Coskun HS: Use of blood transfusion at the end of life: does it have any effects on survival of cancer patients? Asian Pacific journal of cancer prevention : APJCP 2014; 15(10):4251-4254. Leibovitz A, Baumoehl Y, Walach N, Kaplun V, Sigler E, Balan S, Habot B: Medical staff attitudes: views and positions regarding blood transfusion to terminally ill cancer patients. American journal of clinical oncology 2004; 27(5):542-546. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files PalliativecareTable1.pdf Table 1. Demographic characteristics of all included patients with and without palliative care services PalliativecareTable2.pdf Table 2. Comparison of medical resource utilization between patient with and without PCS PalliativecareTable3.pdf Table 3. Utilization of medical resource in relation to cancer and lung disease Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3907428","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":271745912,"identity":"fa282e80-3f5e-409c-88ae-d5899ade42ab","order_by":0,"name":"Chia-Chia Lin","email":"","orcid":"","institution":"Taichung Tzu-Chi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chia-Chia","middleName":"","lastName":"Lin","suffix":""},{"id":271745913,"identity":"9553b09d-260d-4825-ac3d-27a2351c7a09","order_by":1,"name":"Tsing-Fen Ho","email":"","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Tsing-Fen","middleName":"","lastName":"Ho","suffix":""},{"id":271745914,"identity":"afe7c964-92b9-41c6-b449-be7e253a5c01","order_by":2,"name":"Chang-Hung Lin","email":"","orcid":"","institution":"Taichung Tzu-Chi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chang-Hung","middleName":"","lastName":"Lin","suffix":""},{"id":271745915,"identity":"8b86226e-0ab9-4cc0-9c94-6399bfa58266","order_by":3,"name":"Nu-Man Tsai Tsai","email":"","orcid":"","institution":"Chung Shan Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nu-Man","middleName":"Tsai","lastName":"Tsai","suffix":""},{"id":271745916,"identity":"fc03c771-906c-4621-abbf-08796c504c80","order_by":4,"name":"Yu-Hung Kuo","email":"","orcid":"","institution":"Taichung Tzu-Chi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu-Hung","middleName":"","lastName":"Kuo","suffix":""},{"id":271745917,"identity":"be2fb308-286e-4f71-bcbf-757df0dac2b5","order_by":5,"name":"Ju-Huei Chien","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIie3PMQuCQBTA8SfCuRy4Pin6DEYQBoFfxRCaaneKIDiH9LvUEo3eYsu5t6VLe5st0VlLUKltDfcfjjfcj3cHoFL9Zdoy8Uqk5nPGZkBB53kROV2LvZKklhC/n5NgbKcPAs3ENcQQPYp0cArPeN07YIZrT7+wmi10JomDdJjC1IoFAopsA7yOyMuPLZKkHY0h2DiXZNdEiHwY01hbQny7IjbRSUsifJ5PIqSYTvVRzOQg/5Jkt+/ECPmSl+XCNVeH4nhli54Zxts8EN/J+9rqSH4AKpVKpfrQHdS3SvG2oiUrAAAAAElFTkSuQmCC","orcid":"","institution":"Taichung Tzu-Chi Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ju-Huei","middleName":"","lastName":"Chien","suffix":""}],"badges":[],"createdAt":"2024-01-29 01:14:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3907428/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3907428/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51017388,"identity":"97577954-233b-4a75-83b4-d080a3fe472d","added_by":"auto","created_at":"2024-02-12 19:15:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38561,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"PalliativecareFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3907428/v1/7c6d34a699b5e862c05635b7.png"},{"id":51017389,"identity":"f8b694d2-7e67-4162-a2d5-822afff64ae3","added_by":"auto","created_at":"2024-02-12 19:15:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":101041,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of odds ratios for healthcare resource utilization. (A) Without versus palliative care. (B) Palliative intervention before the last hospitalization compared to palliative intervention after the last hospitalization. (C) Patients with cancer who underwent palliative intervention before the last hospitalization compared with palliative intervention after the last hospitalization. (D) Patients with lung disease who underwent palliative intervention before the last hospitalization compared with those who underwent palliative intervention after the last hospitalization.\u003c/p\u003e","description":"","filename":"PalliativecareFigure21.png","url":"https://assets-eu.researchsquare.com/files/rs-3907428/v1/35a53ce61c9f0001eb6723d5.png"},{"id":57897438,"identity":"6c31408f-1c55-4331-9b9a-a21a8c20095a","added_by":"auto","created_at":"2024-06-07 07:59:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":495403,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3907428/v1/97c12a0c-0f72-4489-a7c2-8feb72fa1b05.pdf"},{"id":51017392,"identity":"dc6d26b6-869d-41d0-87ea-0ced1950e308","added_by":"auto","created_at":"2024-02-12 19:15:23","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":207659,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1. Demographic characteristics of all included patients with and without palliative care services\u003c/p\u003e","description":"","filename":"PalliativecareTable1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3907428/v1/d9035d5e87a255f1db10db6d.pdf"},{"id":51017390,"identity":"419b08f3-e2b5-43a1-bc38-1ef99816d3c3","added_by":"auto","created_at":"2024-02-12 19:15:23","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":149170,"visible":true,"origin":"","legend":"\u003cp\u003eTable 2. Comparison of medical resource utilization between patient with and without PCS\u003c/p\u003e","description":"","filename":"PalliativecareTable2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3907428/v1/c0b380a1f52258034cf0a8e9.pdf"},{"id":51018841,"identity":"32218681-a027-4a77-a928-13c808b7b902","added_by":"auto","created_at":"2024-02-12 19:23:23","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":142912,"visible":true,"origin":"","legend":"\u003cp\u003eTable 3. Utilization of medical resource in relation to cancer and lung disease\u003c/p\u003e","description":"","filename":"PalliativecareTable3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3907428/v1/20b5319e034ead164c2ee3b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of early palliative care interventions on the utilization of medical care resources for end-of-life patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePalliative care is becoming increasingly essential as the population ages, and Taiwan, in particular, is undergoing a rapid aging process, ranking among the world\u0026rsquo;s oldest populations. Projections indicate that the average life expectancies will increase from 81.8 years in 2022 to 88.1 years by 2070. By the end of 2025, nearly 20% of the population will be aged 65 or older, which is a super-aged society according to forecasts from the Taiwan National Development Council [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These demographic shifts position Taiwan to have one of the highest proportions of older adults by 2060.\u003c/p\u003e \u003cp\u003eAccording to a WHO survey, only 50% of countries globally have reported having palliative care within their national non-communicable disease policy. Additionally, the availability of palliative care services (PCSs) remains limited for patients diagnosed with a chronic disease globally, and with only 39% of countries further reporting their general availability with regards to reaching at least 50% of patients in need in primary health care and 40% with regards to community- or home-based care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Population aging has become a national crisis that not only affects the entire healthcare system but also the overall economic growth of society. Advancements in technology and medicine have led to the use of medications and life-sustaining tools to prolong life. People with terminal or incurable diseases were treated extensively, and some treatments were futile and ineffective, which could have worsened their condition. Overuse of futile medical interventions to extend life may not only be a family burden but also be counterproductive for the health care system.\u003c/p\u003e \u003cp\u003ePalliative care is currently recognized as the best medical care model for patients nearing the end-of-life. An increasing number of countries are integrating palliative care to facilitate healthcare resource allocation as well as decrease medical waste and social burden. Furthermore, even with the advancements in science and technology, human deaths are unavoidable. PCSs are now widely acknowledged as a specialty in patient management to improve the quality of life of terminally ill patients and better manage their symptoms and disease progression. The combined care between clinical medical professionals with palliative care teams can significantly reduce conflict among professionals, patients, and their families [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Considering the limited medical resources available, integrating PCSs into the national health insurance (NHI) system will not only benefit improving the quality of life for patients nearing their end-of-life but also control the health insurance budget and reduce medical futility [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePalliative care is currently in high demand among patients in Asia, particularly in Taiwan, Japan, and China, for both cancer and non-cancer patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to the 2021 annual report from the Ministry of Health and Welfare in Taiwan, only 62.8% of all cancer patients received such services in the year prior to their death in 2019 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Palliative care in Taiwan\u0026rsquo;s healthcare system has expanded thanks to a scheme implemented by the NHI in 2009 for the reimbursement of palliative care for eight significant non-cancer terminal patients. In 2020, the bureau of Taiwan NHI started to fully support and promote several palliative care projects, including \u0026ldquo;cancer psycho-oncology healthcare training program,\u0026rdquo; \u0026ldquo;Taiwan cancer and non-cancer palliative care outcome collaboration program,\u0026rdquo; \u0026ldquo;building hospice and palliative care resources center program,\u0026rdquo; and \u0026ldquo;compassionate community program for terminal cancer patients.\u0026rdquo; These palliative care insurance plans have contributed to Taiwan\u0026rsquo;s overall improvement and comprehensiveness with regards to the quality of its healthcare system.\u003c/p\u003e \u003cp\u003eHowever, patients, their families, and healthcare professionals still find it difficult to make treatment decisions and manage the utilization of medical resources even after several promotional programs and policies have been implemented. In assessing the quality of medical care at the end of life, various potential quality measures have been employed to measure the level of aggressive and palliative care available [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. There is evidence to support the cost-effectiveness of palliative care with regards to healthcare costs and the decrease in the utilization of aggressive treatments, including ventilation, endotracheal intubation, and resuscitation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Other studies have indicated that patients who receive palliative care at the end of life will have lower hospitalization rates, fewer ICU days, less active treatment, and a reduced length of hospital stay (LOS) when they receive palliative consultations within 72 hours of being admitted to the hospital [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nevertheless, the availability of medical resources can vary depending on the different diseases, clinical practices, and timing of palliative care interventions. It is crucial to understand palliative care interventions and the timing of palliative consultations that patients receive before death to improve their quality of life. This study aimed to examine how healthcare resource utilization differs between patients who received palliative care and those who did not and assessed the medical resource utilization for various diseases and the timing of palliative care intervention during the final hospital admission of patients in end-of-life situations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eA flowchart of the enrollment process for the study cohort is exhibited in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Data on the utilization of medical resources by patients who died at Taichung Tzu-Chi Hospital were retrieved from the hospital information system database from 2019 to 2021 (n\u0026thinsp;=\u0026thinsp;2,454). The exclusion criteria were age\u0026thinsp;\u0026lt;\u0026thinsp;20 years (n\u0026thinsp;=\u0026thinsp;7) or death occurring within 24 hours of hospital administration (n\u0026thinsp;=\u0026thinsp;245). A total of 2,202 patients were included in this study, of whom 1,364 (61.9%) received PCS nearing the end of their lives. In PCS group, 275 (20.2%) of patients received either palliative care or a palliative related consultation before their last hospital admission, and 1,089 (79.8%) received palliative care or a palliative related consultation after their last hospitalization.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn Taiwan, the NHI program covers approximately 99% of residents and is a single-payer system that provides universal insurance coverage for medical services. All residents of Taiwan have free access to medical providers, such as medical centers or clinics. In this study, patients who received palliative care or a related consultation were defined as having admission claims following the NHI palliative care coding three months prior to their death. The NHI codes for palliative physician visits, family palliative consultants, and hospice care in hospitals are P4401B, 02020B, 05601B, 05602B, 05603B, 05362C, and 05364C. Health insurance prescriptions, treatment records, outpatient visits, ER visits, and hospitalization administration of medical history from one year prior to the patient\u0026rsquo;s death were included in the dataset. Patients\u0026rsquo; primary and other diagnoses at the final hospitalization were defined and coded as causes of death according to the International Classification of Diseases, 10th Revision, Clinical Modification. The major diseases were: dementia (ICD-10-CM code: F01-F03), Alzheimer\u0026rsquo;s disease (G30-G32), stroke (I60-I69), heat failure (I50), COPD (J40-J47), diseases of the respiratory system (J00-J99), diseases of liver (K70-K77), acute kidney disease (N17), chronic kidney disease (N18-N19), trauma or bone fracture (S00-S99), sepsis (A40-A41), and cancer/neoplasms (C code).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIndicators of aggressiveness of medical care\u003c/h2\u003e \u003cp\u003eEight dependent indicators of medical care utilization 30 days before death were employed in this study. These indicators included: (1) emergency department visits, (2) hospitalization over a 14-day period, (3) hospitalization over a 30-day period, (4) number of days in the intensive care unit, (5) endotracheal intubation, (6) respiratory ventilation, (7) cardiopulmonary resuscitation (CPR), and (8) blood transfusion. To clarify the effectiveness and timing of PCSs, which included palliative referral, family palliative care consultants, and palliative care in the hospital, the researchers also grouped the palliative care patients into two subgroups: one group included patients who had received palliative care before their last hospitalization, and the other group included patients who received PCSs during their last hospitalization. Additionally, we calculated the LOS at the last hospitalization and the time after hospital admission.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed by making use of the Statistical Analysis System software (version 9.3, SAS Institute Inc., Cary, NC, USA). Patient demographic trends included age, sex, disease diagnosis, LOS, and utilization of medical services. The characteristics of the study cohort were compared by using descriptive statistics. Rates for each indicator for the overall study cohort were compared across the palliative consultants, and a chi-square test with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. The impact of each indicator on the aggressiveness of the end-of-life care was examined by multivariate analysis. Descriptive statistics, frequency of use, percentage, mean, and standard deviation were utilized to describe the demographic characteristics of the study subjects. Different indicators were utilized as categorical variables, and multiple logistic regression was utilized to explore the impact of palliative care before death on the utilization of medical care services at the patients\u0026rsquo; end of life. Considering that a single indicator may not effectively and completely evaluate the quality of medical care at the end of life, the indicators were calculated as a combination of components.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Research Ethics Committee of Taichung Tzu-Chi Hospital (REC 110-71).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eStudy population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 summarizes the demographic characteristics of the 2,202 study participants. Both sexes including 938 (42.6%) female and 1,264 (57.4%) male participants were equally represented. The average age of patients that did not have a palliative consultant was higher (74.9 \u0026plusmn; 14.1) than those that did (70.5 \u0026plusmn; 14.5). The age groups from 21\u0026ndash;40, 41\u0026ndash;60, 61\u0026ndash;80, and \u0026gt; age 80 were 2.0%, 20.3%, 44.0% and 33.7% respectively. With regard to the 1,364 patients that had a palliative consultant, 1,353 (99.2%) of patients received either palliative care or palliative related consultation 1\u0026ndash;3 months prior to their death. The prevalence of patients with three major causes of death and comorbidities such as lung disease, cancer, and sepsis was 61.3%, 53.5%, and 27.4%, respectively, indicating that patients may have had cancer or multiple other chronic diseases. It is also possible for patients to have more than one comorbidity at the end of their lives. The average age for patients that had not received palliative care in comparison to the group that did was 74.1 \u0026plusmn; 4.1 years old vs 70.5 \u0026plusmn; 14.5 years old (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), respectively. There were significant differences in age distribution between the patients that had received palliative care and the patient group that did not (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). Furthermore, in the subgroup of the palliative care patients, the average age of patients that received palliative care before their last hospital admission versus patients that received palliative care after their last hospital admission was 66.3 \u0026plusmn; 13.5 versus 71.7 \u0026plusmn; 14.6 years old, respectively. Additionally, the data exhibited a significant difference in age distributions before and after the patients\u0026rsquo; last hospital admission (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThe patients that visited the Emergency Room (ER) did not exhibit a significant difference between the two groups (73.4% in the no palliative care group vs. 70.5% in the palliative care group, \u003cem\u003eP\u003c/em\u003e = 0.148). Compared to patients without PCS, those with PCS exhibited a reduced utilization of medical resources, including the duration of their stay in ICU (n = 552 vs. n = 439, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), endotracheal intubation (n = 68 vs. n = 151, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), respiratory ventilator use (n = 316 vs n = 444, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), and CPR (n = 32 vs. n = 79, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedical resource utilization\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe utilization rates of aggressive care for the PCS with and without groups are presented in Table 2. The number of ER visits have no differences statistically between the two groups with or without palliative care intervention. The average hospitalization length was 19.0\u0026nbsp;\u0026plusmn;\u0026nbsp;9.1 days versus 15.8\u0026nbsp;\u0026plusmn;\u0026nbsp;10.3 days (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and the duration of the stay in ICU was 3.7\u0026nbsp;\u0026plusmn;\u0026nbsp;6.7 days versus 5.8\u0026nbsp;\u0026plusmn;\u0026nbsp;7.1 days (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) in palliative care and non-palliative care groups, respectively. However, the number of blood transfusion units increased significantly from 2.6\u0026nbsp;\u0026plusmn;\u0026nbsp;5.1 in the PCS group to 3.4\u0026nbsp;\u0026plusmn;\u0026nbsp;5.8 in the group without PCS.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe medical resource utilization between cancer and lung disease\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 compares healthcare resource utilization between patients with cancer and lung disease who received palliative care before or after hospital admission. Regarding these cancer patients, 57.8% were male and 42.2% were female, and the proportions of patients aged 21\u0026ndash;40, 41\u0026ndash;60, 61\u0026ndash;80, and \u0026gt; 80 years were 28 (2.9%), 267 (28.1%), 484 (50.9%), and 171 (18.0%), respectively. Palliative care and consultant services before the final hospitalization or in the post-hospitalization period did not differ significantly based on sex. However, with regards to age, the age of patients receiving palliative services after hospitalization is significantly older than that of patients receiving palliative services before hospitalization (66.3\u0026nbsp;\u0026plusmn;\u0026nbsp;11.5 years old vs 71.7\u0026nbsp;\u0026plusmn;\u0026nbsp;14.6 years old).\u003c/p\u003e\n\u003cp\u003eIn this study, there was a lower proportion of patients who were hospitalized for a period over 14 days (19.0 % vs 57.5%, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) as well as those who were hospitalized for a period over 30 days (17.3% vs 18.3 %, \u003cem\u003eP\u003c/em\u003e = 0.007) compared to the PCS group of patients who received care before and after hospital admission. However, in terms of the proportion of patients utilizing other healthcare resources, there was no significant difference between cancer patients before and after hospital admission (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Among the lung disease patients, 60.7% were male and 39.3% were female, and the proportions of patients aged 21\u0026ndash;40, 41\u0026ndash;60, 61\u0026ndash;80, and \u0026gt;80 years old were 20\u0026nbsp;(2.7%), 124 (16.9%), 323 (44.1%), and 265 (36.2%), respectively. The proportion of individuals over age 80 was higher in the cancer group. Patients with lung disease exhibited significant differences in receiving palliative care before or after hospital admission during hospitalization over a period of 14 days: 41.0% vs 64.4% (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), hospitalization over a period of 30 days: 13.1% vs 27.0% (\u003cem\u003eP\u003c/em\u003e = 0.001), ICU stay: 33.6% vs 51.0% (\u003cem\u003eP\u003c/em\u003e = 0.001), and use of respiratory ventilation: 24.6% vs 39.7% (\u003cem\u003eP\u003c/em\u003e = 0.002).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePotential associated factors for receiving palliative care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the univariate logistic regression of factors associated with healthcare services utilized in patients in our study cohort, the likelihood of palliative patients stays in regular care ward over 14 days and over 30 days were (odds ratio [OR] = 1.95, 95% confidence interval [CI]: 1.62\u0026ndash;2.35, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and OR = 1.46, 95% CI: 1.15\u0026ndash;1.86, \u003cem\u003eP\u003c/em\u003e = 0.002). Other than the duration of hospitalization, patients who received palliative care were associated with lower odds with regard to the utilization of aggressive medical care resources, including ICU (OR = 0.47, 95% CI: 0.38\u0026ndash;0.58, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), endotracheal tube procedures (OR = 0.27, 95% CI: 0.19\u0026ndash;0.37, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), respiratory ventilator use (OR = 0.43, 95% CI: 0.35\u0026ndash;0.53, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), CPR (OR = 0.25, 95% CI: 0.17\u0026ndash;1.01, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), and blood transfusion (OR = 0.82, 95% CI: 0.67\u0026ndash;1.01, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). However, in this study cohort, only ICR admissions (OR = 0.47, 95% CI: 0.38\u0026ndash;0.58, \u003cem\u003eP\u003c/em\u003e = 0.365) did not indicate a statistical significance (Figure 2A).\u003c/p\u003e\n\u003cp\u003eIn comparison, in the subgroups who received palliative care before and after the last hospitalization, the patients who had PCS either by referral or through a family consultant before their last hospitalization exhibited a decrease in healthcare resource utilization during the length of their hospital stay \u0026gt;14 days (OR = 0.40, 95% CI: 0.30\u0026ndash;0.53, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), \u0026gt; 30 days (OR = 0.45, 95% CI: 0.29\u0026ndash;0.69, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), and respiratory ventilator use (OR = 0.57, 95% CI: 0.37\u0026ndash;0.87, \u003cem\u003eP\u003c/em\u003e = 0.009). However, in Taiwan, most patients still have a high likelihood of visiting the ER prior to hospital admission (OR = 1.82, 95% CI: 1.32\u0026ndash;2.53, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) even if they have been introduced to a PCS or consultant (Figure 2B).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUtilization of aggressive medial resource among different diseases\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn a comparison between the cancer and non-cancer utilization of different medical resources, we measured the effectiveness between cancer and lung disease patients. Palliative care intervention before and after the last hospital admission was utilized as a variable. Figures 2C and 2D exhibit the palliative care intervention before and after the last hospital admission, respectively, in the cancer patient cohort. There was no statistical significance for ICU stay (OR = 0.84, 95% CI: 0.55\u0026ndash;1.27, \u003cem\u003eP\u003c/em\u003e = 0.403), endotracheal intubation (OR = 0.8, 95% CI: 0.35\u0026ndash;1.71, \u003cem\u003eP\u003c/em\u003e = 0.528), respiratory ventilator use (OR = 0.69, 95% CI: 0.43\u0026ndash;1.11, \u003cem\u003eP\u003c/em\u003e = 0.127), CPR (OR = 1.90, 95% CI: 0.68\u0026ndash;5.28, \u003cem\u003eP\u003c/em\u003e = 0.221), and blood transfusion (OR = 0.98, 95% CI: 0.72-1.32, \u003cem\u003eP\u003c/em\u003e = 0.876).\u003c/p\u003e\n\u003cp\u003eThe association of palliative care intervention before the last hospital admission in lung disease patients was also associated with a shorter length of stay in the hospital \u0026gt;14 days, \u0026gt;30 days, and in the ICU (OR = 0.41, 95% CI: 0.27\u0026ndash;0.62, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001; OR = 0.46, 95% CI: 0.26\u0026ndash;0.83, P = 0.009; OR = 0.62, 95% CI: 0.39\u0026ndash;0.98, \u003cem\u003eP\u003c/em\u003e = 0.042, respectively). Additionally, respiratory ventilator use is also decreasing compared with patients receiving palliative care after hospital admission (OR = 0.56; 95% CI: 0.35\u0026ndash;0.91, 95% CI: 0.35\u0026ndash;0.91, \u003cem\u003eP\u003c/em\u003e = 0.019). The utilization of an endotracheal tube, CPR, and blood transfusion did not exhibit significant differences statistically (OR = 0.54, 95% CI: 0.21\u0026ndash;1.34, P = 0.181; OR = 1.20, 95% CI: 0.37\u0026ndash;3.88, \u003cem\u003eP\u003c/em\u003e = 0.756; OR = 1.14, 95% CI: 0.74\u0026ndash;1.76, \u003cem\u003eP\u003c/em\u003e = 0.558, respectively).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAll patients with life-limiting illnesses need palliative care to improve the quality of life for themselves and their families. Palliative care has been recommended as the standard of care for any patient diagnosed with advanced cancer [14-16]. In the past, the focus has primarily been on cancer patients, and palliative care has only recently gained recognition for patients with chronic and other illnesses. Multiple studies have indicated that in recent years, the use of palliative care has increased amongst non-cancer patients [17, 18]. However, palliative care has also been seen to be closely related to the utilization of medical resources. This study collected data from the end-of-life patients within an institution to investigate the utilization of palliative medical resources. The patient population in palliative care included both patients with cancer and individuals with chronic illnesses. The results revealed that using early integrated palliative care interventions can effectively reduce the utilization of medical resources.\u003c/p\u003e\n\u003cp\u003eIt is worth noting that palliative medical resources decreased in endotracheal intubation, respiratory ventilation, and CPR, but increased in the number of days that the patients stayed hospitalized and in the ICU with end-stage cancer. In Taiwan, the NHI covers almost 99.9% of the resident population. Even when receiving palliative care, patients who experience physical discomfort or illness may seek medical attention or hospitalization. The tendency to use medical services is influenced by factors such as actual healthcare utilization, benefits of unique healthcare plans, and specificities of the healthcare insurance system. Moreover, the presence of ERs in most local hospitals makes healthcare services very convenient for patients and helps maintain affordable healthcare costs. Almost half of accidental hospitalizations occur during visits to the ER. As a result, patients receiving PCSs may experience an impact on ER visits, LOS, ICU admission, and utilization of other healthcare resources. Previous studies have highlighted that the palliative care integration project has resulted in a significant better documentation of pain, fewer visits to the ER [19], and fewer admissions to acute care hospitals [20, 21]. However, in our study cohort, the likelihood of ER visits was higher compared to other studies. The propensity to use medical services is associated with factors such as actual health care utilization, the beneficial effect of a unique healthcare program, and the special characteristics of the medical insurance system [22]. A high percentage of patients who had ER visits in the last month before death, even in the palliative care group, has been demonstrated in our findings. Additionally, our results also indicated a secular trend of a decrease in the utilization of aggressive care, such as the use of endotracheal tubes, respiratory equipment, ICU hospitalization, CPR, and blood transfusion, in the palliative care group compared to the no palliative care group.\u003c/p\u003e\n\u003cp\u003eSince 1995, cancer patients and other patients with severe illnesses have been eligible to apply for a \u0026ldquo;catastrophic illness certificate,\u0026rdquo; and certified patients are exempt from medical payments in Taiwan. Based on this, a higher proportion of cancer patients from the emergency department visit more than once in the last month of their lives [23]. The referral timing or provision of a palliative care consultant is difficult to define and investigate. During disease prognosis, patients with cancer may discuss with or consult a palliative care team. By contrast, older or severely ill patients are more likely to receive information about palliative care after a series of aggressive treatments in hospitals. The results indicate that the timing of palliative care intervention is a determining factor in the decrease of the length of the patient\u0026rsquo;s hospital stay. Moreover, early palliative care intervention also influences the decision to utilize aggressive medical care resources, such as endotracheal intubation, respiratory ventilation, or even CPR, in patients with different severe illnesses. Consequently, palliative care has been found to improve patients\u0026rsquo; quality of life, decrease aggressive end-of-life care, and reduce medical costs.\u003c/p\u003e\n\u003cp\u003eThe use of aggressive care and medical resources varies between patients that experience different diseases and comorbidities. Lung disease is a major cause of morbidity and death in the older adult population, and disease prognosis may occur quickly and throughout the whole body through severe infections and jeopardize life within a few hours or days. However, introducing palliative care to patients with lung disease or severe infection before their last hospitalization, is lesser in proportion, compared to cancer patients (n = 122, 16.7% vs n = 247, 26.0%, Table 3). Patients with lung disease or infection are more likely to experience common clinical symptoms such as fever, nausea, vomiting, dyspnea, changes in consciousness, and even gastrointestinal bleeding. Older adult patients with an infectious condition also increased the number of repetitive hospital visits, prolonged hospitalization, and admissions to the intensive care unit [24]. Other JAMA study also reported that 40% of patients who died of sepsis in the hospital were eligible for palliative care, however, they were never referred to hospice care before admission to the hospital [25]. Patients with lung infection or sepsis are commonly prescribed with antibiotic therapy and must be admitted to the hospital. When patients develop severe sepsis associated with other acute or chronic diseases such as cancer, and their life expectancy is predicted to be within six months or less, palliative care integration may help reduce unnecessary treatment and provide better pain management and symptom control. Our data indicates a pattern of decreased aggressive care at the end of life in association with the length of hospitalization, ICU stay, and respiratory ventilator use in patients with lung disease who received PCSs prior to their last hospital admission. \u003c/p\u003e\n\u003cp\u003ePatients with cancer who received palliative care showed reduced endotracheal intubation, respiratory ventilation, CPR, and blood transfusion compared to patients with lung disease. However, for patients with cancer, there were no significant differences in utilizing aggressive treatment in palliative care before or after hospitalization. In contrast, in patients with lung disease, there were significant differences in the LOS, ICU stay, and respiratory ventilator use. The timing of palliative care in patients with chronic illnesses remains controversial.\u003c/p\u003e\n\u003cp\u003eA late referral to PCSs may extend the length of hospitalization and lead to delays in palliating patients in need. Furthermore, some patients may undergo aggressive procedures such as endotracheal intubation or respiratory ventilation before palliative care referral. In these circumstances, palliative care may not help improve the quality of life for chronic illness patients at their end of life.\u003c/p\u003e\n\u003cp\u003eCPR is an important and progressive life-saving procedure for critically time-sensitive patients and those with heart failure. Resuscitation procedures were performed in approximately 1.9 ~5% of all emergency department visits [19, 26]. The statistics show that, excluding patients with chronic kidney disease and heat failure cases, those who received palliative care used life-sustaining treatments less frequently, avoided further resuscitation, and possibly reduced using ineffective medicines.\u003c/p\u003e\n\u003cp\u003eTransfusions are a crucial component of aggressive and palliative medical care. For both palliative care and older adults at the end of life, transfusion aims at bringing supportive care [27]. In this study, the prevalence of transfusion in the palliative care group is lower than without palliative care group (55.9%, vs 62.8%, P \u0026lt; 0.001; Table 1), and the average amount of blood transfused was 2.6 \u0026plusmn; 5.1 vs 3.4 \u0026plusmn; 5.8 (Table 2). In fact, the severity and consequences of anemia can worsen owing to additional factors such as comorbidities, malnutrition, inadequate dietary intake, and decreased physical capabilities and organ functions. Consequently, the evaluation and criteria for blood transfusion may not applicable for palliative care populations [28]. Another issue for consideration is the availability and allocation of RBCs: a finite resource [29]. High prevalence of anemia (as high as 98%) has been observed in the ICU [28], and approximately 27.0%\u0026ndash;62.1% with moderate to mild anemia during hospital stay in pneumonia patients [30, 31]. Patients who had blood transfusions at the end of life lived significantly longer than anemic patients who were not transfused and could survive longer (15 days vs 8 days) [32, 33]. Even though RBC transfusion only aims to directly treat a small portion of medical problems faced by patients receiving palliative care, particularly to improve the symptomatic anemia that may help to prolong their life in some situations. The overall blood transfusion rate reduces the odds of receiving palliative care. However, these rates differ depending on the patient\u0026rsquo;s medical care and disease.\u003c/p\u003e\n\u003cp\u003eThe government healthcare system and insurance policies also play critical roles in determining the type and quality of patients receiving medical care. Unlike other countries, NHI in Taiwan is a compulsory program that all citizens and legal residents must join. The payment system of the NHI covers almost all medical care expenses, including emergency visits, medication, dental services, dialysis, surgery, organ transplantation, hospitalization, and home-based medical care. The universal payment system makes healthcare affordable for everyone and avoids inequality and discrimination among patients with low-income or disadvantaged populations. Moreover, the government promotes and changes policies from focusing on cancer-related palliative care to non-cancer-related sickness to provide better and more comprehensive care for older adults and enhance the utilization of palliative care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study had some limitations. It was based on the retrospective medical records of 2,202 patients who died in hospitals between 2019 and 2021. Medical records of PCSs and patient diagnoses were provided by Tzu-Chi hospital, and other home palliative care or medical care information were not included. Terminally ill patients who were admitted to the emergency department or hospitalized but died within 24 hours were excluded from this study. Additionally, the causes of death and comorbidities were based on 11 major diagnostic ICD-10 codes, which may not include other causes of death.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA conflict always exists between prolonging life and delaying death. Despite numerous advances in technological interventions and pioneering pharmacology, individuals live longer with life-threatening illnesses such as cancers and other chronic severe illnesses. There are few chances for medical professionals to snatch patients with illnesses back from the brink of death and restore some patients to a healthy life. However, when death is on a predictable trajectory of the disease, physicians and caregivers should focus on providing tranquility for patients through physical, psychological, and other appropriate support to relieve their pain and suffering. Nowadays, doctors still secularly cogitation as \u0026ldquo;life-sever\u0026rdquo; as treating patient recovered. Older adult patients with chronic illnesses often find themselves in an uncomfortable state between the thresholds of life and death. When facing the dying, not only patients and their families, but also medical professionals may undergo various stages as grief or powerless. Nowadays, doctors still secularly cogitation as \u0026ldquo;life-sever\u0026rdquo; as treating patient recovered. Older adult patients with chronic illnesses often find themselves in an uncomfortable state between the thresholds of life and death. When death becomes inevitable, patients may endure a state of medical purgatory, where they rely on life-sustaining interventions, such as tracheal ventilators or catheters extending from their abdomen or bladder, causing significant discomfort. Patients are continuously uncomfortable and experience pain when they are awake; most of the time, they may be sedated while sleeping to relieve pain. Nevertheless, medical caregivers often face an internal conflict about whether they should prolong the patient\u0026rsquo;s life as much as possible, even if it is just for a few days or weeks, to avoid being accused of failing of treat the patient, or tell the patient and their family that it is perhaps the time to \u0026ldquo;let go\u0026rdquo; and allow the patient to pass with comfort and dignity.\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s autonomy in making end-of-life and do not resuscitate decisions is more respected, and palliative care acceptance has been growing recently. The traditional idea of palliative care, which involves letting the patient die, is undergoing a transformation. Palliative care consulting provides more information to patients to optimize their end-of-life quality and benefits the healthcare system. An increasing number of hospitals provide palliative care in their health care, and patients can choose alternative options for themselves from painful, inhuman, and ineffective treatments. Palliative care could be a better solution to wrench distress and disagreement in medical, physical, social, and spiritual care for patients and their families, as well as medical professionals, and redeem terminally ill patients with dignity at the end of life.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003ePCSs: Palliative care services; NHI: National health insurance; CPR: Cardiopulmonary resuscitation; ER: Emergency room; OR: Odds ratio; CI: Confidence interval; LOS: Length of hospital stay\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to specially thank the palliative care team members for their continuous support and understanding during this study and for improving this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.-C.L and C.-H.L.: resources, methodology, data curation; T.-F.H.: conceptualization, formal analysis, writing\u0026mdash;review and editing; N.-M. T.: review; Y.-H.K.: investigation, statistical analysis; J.- H.C.: conceptualization, data curation, and writing\u0026mdash;original draft preparation. All the authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the ministry of education of Taiwan (PMN1122369), and\u0026nbsp;the Taichung Tzu- Chi Hospital, Taichung, Taiwan (TTCRD112-27). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author confirms that all data generated and analyzed during this study are included in this published article. The data sets analyzed during the current study contain patient medical information, they are not publicly available due to the patient protection policy of Tzu Chi Hospital. Inquiries related to the study data and protocol can be sent to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and patient consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been approved by the Ethics Committee of the Taichung Tzu- Chi Hospital (REC 111-02). All medical records in this study are deidentified. For this study, the informed consent was waived by the research ethics committee of Taichung Tzu-Chi Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePopulation Estimates and Manpower Estimates for the Republic of China (Taiwan). Department of Human Resources Development National Development Council 2023.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global atlas of palliative care (2nd edition). The Worldwide Hospice Palliative Care Alliance, https://www.thewhpca.org/resources/global-atlas-on-end-of-life-care (accessed 9 July 2023).\u003c/li\u003e\n\u003cli\u003eQuinn KL, Stukel T, Stall NM, Huang A, Isenberg S, Tanuseputro P, Goldman R, Cram P, Kavalieratos D, Detsky AS et al: Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study. BMJ (Clinical research ed) 2020; 370:m2257.\u003c/li\u003e\n\u003cli\u003eChang TS, Su YC, Lee CC: Determinants for aggressive end-of-life care for oral cancer patients: a population-based study in an Asian country. Medicine 2015; 94(4):e460.\u003c/li\u003e\n\u003cli\u003eEarle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ: Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? 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Journal of intensive care medicine 2018; 33(6):346-353.\u003c/li\u003e\n\u003cli\u003eDavis MP, Van Enkevort EA, Elder A, Young A, Correa Ordonez ID, Wojtowicz MJ, Ellison H, Fernandez C, Mehta Z: The Influence of Palliative Care in Hospital Length of Stay and the Timing of Consultation. The American journal of hospice \u0026amp; palliative care 2022; 39(12):1403-1409.\u003c/li\u003e\n\u003cli\u003eHaun MW, Estel S, R\u0026uuml;cker G, Friederich HC, Villalobos M, Thomas M, Hartmann M: Early palliative care for adults with advanced cancer. The Cochrane database of systematic reviews 2017; 6(6):Cd011129.\u003c/li\u003e\n\u003cli\u003eParikh RB, Kirch RA, Smith TJ, Temel JS: Early specialty palliative care--translating data in oncology into practice. The New England journal of medicine 2013; 369(24):2347-2351.\u003c/li\u003e\n\u003cli\u003eTemel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA, Back AL, Kamdar M, Jacobsen J, Chittenden EH et al: Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2017; 35(8):834-841.\u003c/li\u003e\n\u003cli\u003eMounsey L, Ferres M, Eastman P: Palliative care for the patient without cancer. Australian journal of general practice 2018; 47(11):765-769.\u003c/li\u003e\n\u003cli\u003eKim S, Lee K, Kim S: Knowledge, attitude, confidence, and educational needs of palliative care in nurses caring for non-cancer patients: a cross-sectional, descriptive study. 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BMJ open 2013; 3(5).\u003c/li\u003e\n\u003cli\u003evan Loenen T, van den Berg MJ, Faber MJ, Westert GP: Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries. BMC health services research 2015; 15:465.\u003c/li\u003e\n\u003cli\u003eTang ST, Wu SC, Hung YN, Huang EW, Chen JS, Liu TW: Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000-2006. Annals of oncology : official journal of the European Society for Medical Oncology 2009; 20(2):343-348.\u003c/li\u003e\n\u003cli\u003eNasa P, Juneja D, Singh O: Severe sepsis and septic shock in the elderly: An overview. World journal of critical care medicine 2012; 1(1):23-30.\u003c/li\u003e\n\u003cli\u003eRhee C, Jones TM, Hamad Y, Pande A, Varon J, O\u0026apos;Brien C, Anderson DJ, Warren DK, Dantes RB, Epstein L et al: Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA network open 2019; 2(2):e187571.\u003c/li\u003e\n\u003cli\u003eLin CY, Lee YC: Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care - a nationwide matched-pair retrospective cohort study in Taiwan. BMC palliative care 2020; 19(1):87.\u003c/li\u003e\n\u003cli\u003eGarraud O: Transfusion at the border of the \u0026quot;intention-to-treat\u0026quot;, in the very aged person and in palliative care: A debate. Transfusion clinique et biologique : journal de la Societe francaise de transfusion sanguine 2021; 28(4):367-369.\u003c/li\u003e\n\u003cli\u003eThomas J, Jensen L, Nahirniak S, Gibney RT: Anemia and blood transfusion practices in the critically ill: a prospective cohort review. Heart \u0026amp; lung : the journal of critical care 2010; 39(3):217-225.\u003c/li\u003e\n\u003cli\u003eRaval JS, Cooling LL: Red blood cell transfusion in palliative care: what are we doing and why are we doing it? Transfusion 2018; 58(1):3-4.\u003c/li\u003e\n\u003cli\u003eReade MC, Weissfeld L, Angus DC, Kellum JA, Milbrandt EB: The prevalence of anemia and its association with 90-day mortality in hospitalized community-acquired pneumonia. BMC pulmonary medicine 2010; 10:15.\u003c/li\u003e\n\u003cli\u003eCzempik PF, Wilczek D, Herzyk J, Krzych Ł J: Hospital-Acquired Anemia in Patients Hospitalized in the Intensive Care Unit: A Retrospective Cohort Study. Journal of clinical medicine 2022; 11(14).\u003c/li\u003e\n\u003cli\u003eGoksu SS, Gunduz S, Unal D, Uysal M, Arslan D, Tatli AM, Bozcuk H, Ozdogan M, Coskun HS: Use of blood transfusion at the end of life: does it have any effects on survival of cancer patients? Asian Pacific journal of cancer prevention : APJCP 2014; 15(10):4251-4254.\u003c/li\u003e\n\u003cli\u003eLeibovitz A, Baumoehl Y, Walach N, Kaplun V, Sigler E, Balan S, Habot B: Medical staff attitudes: views and positions regarding blood transfusion to terminally ill cancer patients. American journal of clinical oncology 2004; 27(5):542-546.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Early palliative care interventions, Medical care resources, End-of-life patients, Medical futility","lastPublishedDoi":"10.21203/rs.3.rs-3907428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3907428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePalliative care is gaining importance, particularly with the aging population. In Taiwan, the availability of palliative care has expanded, supported by reimbursement initiatives from the Taiwan National Health Insurance. The healthcare system in Taiwan is currently integrating more comprehensive palliative care payment benefit plans. However, incorporating palliative care services into the medical care of critically ill individuals nearing the end of life presents several challenges. This study aims to examine the impact of palliative care on the utilization of medical resources in end-of-life scenarios.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 2,202 patients were included in this study. The primary diagnosis and intervention for palliative referral and consultation were based on the HNI code. Additionally, eight dependent indicators of medical resource utilization,30 days before death, were employed in this study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eHospice care for end-of-life patients was associated with less medical resource and aggressive care in the 30 days before death, including intensive care unit use (odds ratio [OR]\u0026thinsp;=\u0026thinsp;0.468, 95% confidence interval [CI], 0.378\u0026ndash;0.579, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, cardiopulmonary resuscitation ([OR]\u0026thinsp;=\u0026thinsp;0.247, 95% CI: 0.154\u0026ndash;0.394, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, endotracheal intubation ([OR]\u0026thinsp;=\u0026thinsp;0.266, 95% CI: 0.191\u0026ndash;0.372, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respiratory ventilator support ([OR]\u0026thinsp;=\u0026thinsp;0.431, 95% CI: 0.348\u0026ndash;0.533, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and blood transfusion ([OR]\u0026thinsp;=\u0026thinsp;0.819, 95% CI: 0.667\u0026ndash;1.005, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0555).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients at the end-of-life who received palliative care experienced a reduced incidence of aggressive medical interventions before death. These encompassed activities such as stays in the intensive care unit, cardiopulmonary resuscitation, endotracheal intubation, respiratory ventilator support, and blood transfusions. The utilization of medical resources varies among patients based on their specific diseases and comorbidities. Early intervention of palliative care or consultation, both for cancer and chronic disease patients, tends to result in less aggressive medical care interventions, including endotracheal intubation, respiratory ventilation, or even cardiopulmonary resuscitation in patients with severe illnesses.\u003c/p\u003e","manuscriptTitle":"The impact of early palliative care interventions on the utilization of medical care resources for end-of-life patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-12 19:15:17","doi":"10.21203/rs.3.rs-3907428/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa0938db-c889-43a7-8993-265528e7475f","owner":[],"postedDate":"February 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-07T07:51:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-12 19:15:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3907428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3907428","identity":"rs-3907428","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}