title: From whole brain to hospice: patterns of care in radiation oncology.
abstract: OBJECTIVE
  The development of brain metastases is a common cause of morbidity and mortality in cancer patients. Limited life expectancy is well established once a patient requires whole-brain radiotherapy (WBRT). There is emerging evidence demonstrating the value of involving palliative care services alongside traditional treatments. However, data regarding the utilization of these services in patients requiring WBRT remain unexplored.
  
  
  METHODS
  Patients with histologic or radiographic evidence of brain metastases treated with WBRT alone between July 2010 and June 2012 were reviewed retrospectively. Patient demographics, the number of hospital admissions in the last 6 months of life, survival, and referrals to palliative care services were evaluated.
  
  
  RESULTS
  Ninety-eight patients were diagnosed with brain metastases and treated with WBRT alone. The median overall survival following WBRT was 80 days. Twenty-eight of the patients presented to the emergency department ≥2 times in the last 6 months of life. Sixty-eight percent of patients were referred to palliative care. Of those referrals, 57% were during an inpatient hospitalization. The median survival from palliative care referral to death was 27 days.
  
  
  CONCLUSIONS
  Patients with brain metastasis requiring WBRT have a predictable dying trajectory. These patients are likely to have a high symptom burden and would benefit from palliative care. Timely palliative care referrals in this population remain inadequate and classically follow a hospital admission. Referrals continued to be late in the dying process and the recommendation for WBRT can be used as an independent marker for initiating end-of-life discussions and involving palliative care.
authors.affiliation: 1 Department of Radiation Oncology, Vanderbilt University Medical Center , Nashville, Tennessee.
authors.forename: Mark
authors.initials: M
authors.lastname: Stavas
authors.forename: Kyle
authors.initials: K
authors.lastname: Arneson
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Friedman
authors.forename: Sumathi
authors.initials: S
authors.lastname: Misra
mesh_terms: D000328:Adult; D000368:Aged; D001932:Brain Neoplasms / Q000532:radiotherapy* / Q000556:secondary; D016371:Cranial Irradiation / Q000379:methods / Q000592:standards*; D005260:Female; D017051:Hospice Care / Q000379:methods / Q000592:standards*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000706:statistics & numerical data*; D011379:Prognosis; D018787:Radiation Oncology / Q000379:methods / Q000592:standards*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D019452:Terminally Ill; D013997:Time Factors