Cuidados de fim de vida em doentes oncológicos em hemodiálise

Abstract

Introduction: Palliative Care (PC) improves end-of-life care quality and reduces healthcare costs for cancer patients. Despite its importance, little is known about PC practices in patients with Chronic Kidney Disease (CKD), particularly those undergoing hemodialysis. Objective: To analyze the quality of end-of-life care, referral to PC, and healthcare costs in the last three months of life for cancer patients on a regular hemodialysis program (RHP). Methods: This is a retrospective, observational cohort study. It included cancer patients with a primary and/or secondary diagnosis of CKD, aged ≥18 years, on RHP, who died at a Portuguese institution dedicated to the treatment of cancer patients between January 2012 and December 2023. Clinical records of the eligible population were reviewed using a form that included various variables, namely Number of hospital admissions, days of hospital stay, surgical procedures, vascular access interventions, Intensive Care Unit (ICU) admission, cardiopulmonary resuscitation, in-hospital death, healthcare costs and referral to PC, in the last 3 months of life. Data were analyzed using SPSS® software (p=0.05). The study received prior approval from the institution's ethics committee. Results: The study included 110 patients with a mean age of 75,3 years (SD=11 months) and a mean time on hemodialysis of 53,9 months (SD=53,8 months). Overall, 79,1% of the patients had solid tumors, with 48,3% of these presenting metastasis. Additionally, 45,5% had progressive cancer, and 10,9% did not receive targeted therapy. Regarding comorbidities, 66,4% had congestive heart failure (CHF), 31,8% were diabetic, and 14,5% had dementia. Only 14,5% were not hospitalized in the last three months of life. Of the 110 patients, 57,3% were not referred to PC. However, among the referred patients (42,7%), 37,3% received an early referral. Patients referred to PC had fewer hospitalizations (p=0.008), fewer surgical procedures in the last three months of life (p=0.001), fewer ICU admissions, and consequently fewer cardiopulmonary resuscitation attempts (p<0.001), compared to those not referred to PC. Referred patients also had fewer days of hospitalization, lower in-hospital mortality rates and lower associated costs, although these findings were not statistically significant. Conclusion: The number of patients referred to PC is lower than desired, even when there is progressive functional decline and a short-term poor prognosis. The results reflect that referral to PC for cancer patients on RHP is associated with better quality of life in the last months, evidenced by a reduced need for aggressive interventions and hospitalizations, as well as a decrease in in-hospital deaths, suggesting a more comfort-focused and patient-centered approach.