Palliative care is underused for patients with malignant urinary obstruction, say researchers

Less than half of patients with malignant ureteral obstruction (MUO)—a serious complication of advanced cancer, with a poor prognosis—receive palliative care (PC) for their condition, reports a paper in the January issue of Urology Practice.

Hospice care can promote patient comfort while avoiding aggressive and invasive treatments for MUO patients nearing the end of life, according to the new research led by Michael D. Felice, MD, of Loyola University Medical Center, Maywood, Ill. "Earlier referral to palliative care might help to promote informed decisions about preferences for care among patients with MUO," Dr. Felice comments.

New insights into palliative care use in MUO

Malignant ureteral obstruction is a condition in which the urinary tract is blocked due to advanced cancer. Patients with MUO have limited life expectancy, and some spend much of their remaining life in the hospital. Over time, MUO leads to buildup of urine within the kidneys, a condition called hydronephrosis. Decompression treatments can relieve the buildup, but these are invasive procedures with high complication rates and sometimes questionable benefits.

For patients with advanced cancer, palliative care aims to improve symptoms and mental and spiritual health while ensuring that any further cancer treatments reflect the patients' goals of care. Hospice care, a subset of palliative care, is an option for patients with expected survival of less than six months.

"Concurrent dedicated palliative care services and oncologic treatment is recommended for patients with advanced cancer," Dr. Felice and colleagues write. However, the use of palliative care by patients with MUO remains unclear. The researchers evaluated the use of palliative care and hospice care among 115 patients diagnosed with MUO between 2014 and 2020.

On review of medical records, only 39% of patients with MUO received palliative care. On average, there was a two-month delay between MUO diagnosis and palliative care evaluation. Just five of 45 patients were referred to palliative care before decisions regarding decompression treatment.

Urologists could play key role in early palliative care referral

Fifty-four percent of patients received hospice care, starting a median of 144 days after MUO diagnosis. Median time from hospice initiation to death was 12 days.

Eighty-five percent of patients died or were presumed to have died at the time of the study. Median time from MUO diagnosis to death was 141 days, with similar survival for patients who did and did not receive palliative care.

Of the patients who died, 43% had high health care use—based on factors such as repeated emergency department visit or hospitalizations during the last month of life, or in-hospital death. Among patients who did not receive hospice care, 86% had high end-of-life health care use.

"This highlights the impact of hospice in facilitating end-of-life discussion and enabling patients to decide how and where they spend their last days," the researchers write. On adjusted analysis, patients receiving hospice care were 97% less likely to have high health care use at the end of life.

Patients with MUO "are ideal candidates for palliative care consultation to help navigate the complexities of multidisciplinary care and guide decision-making," Dr. Felice and co-authors write. "Ideally, patients would be referred to PC after MUO diagnosis and prior to the decision regarding urinary decompression."

The researchers note that 80% of study patients with MUO saw a urologist at some point during their care. They conclude, "Urologists may be particularly poised to promote interdisciplinary collaboration and initiate conversations regarding incorporating palliative care due to our multifaceted involvement in caring for patients with MUO."