Exploring the Definitions and Outcomes of Early Palliative Care Criteria in Individuals with Advanced Lung Cancer: A Multiple Method Study

Abstract

Background: In Ontario, about 51.9% of decedents have palliative care records in their last year, but only 1/5 access publicly funded home care. Early specialist palliative care may boost home service use and lower hospital visits. Early palliative care (EPC) has multiple definitions, and this thesis aims to identify these definitions, assess their applicability to health data, and analyze them using EOL outcomes. Objectives: This dissertation aimed to review and synthesize EPC definitions for individuals with life-limiting chronic illnesses (cancer and non-cancer) to inform criteria; establish consensus on defining EPC using administrative data for advanced cancer patients in Ontario; and examine associations between EPC criteria and quality indicators using ICES data. Methods: This dissertation was completed using multiple methods. For objective 1, a scoping review was conducted, following the Joanna Briggs Institute Methodology. Objective 2 used review results and a consensus method with pre-set criteria in a modified Delphi study. For objective 3, a population-based retrospective cohort study analyzed administrative data from ICES. Results: EPC definitions in literature vary, including initiation and implementation. A scoping review of 153 articles identified five EPC criteria categories: time-based, prognosis-based, location-based, treatment-based, and symptom-based. From these, five criteria applicable to lung cancer patients using ICES data were condensed into three: 1) time-from-index (disease to first palliative care), 2) time-before-death (care >3 months before death), and 3) first-care setting (outpatient). These were analyzed for associations with supportive and aggressive EOL indicators. Time-from-index (0-4 and 4-8 weeks) correlated with fewer aggressive and more supportive indicators. Time-before-death showed similar patterns, as did first-care setting EPC criteria. Conclusions: This dissertation shows variability in defining EPC but confirms its importance and link to better end-of-life quality indicators. Different time-based definitions serve different purposes, reflecting various aspects of care. Examining evidence-based definitions has highlighted the pros and cons of each approach, which is vital for analyzing EPC interventions. Ultimately, creating a standardized, patient-centred definition incorporating timing, location, and needs is key for equitable access and optimal outcomes.