Early palliative care decision is associated with reduced end-of-life healthcare utilization in patients with esophageal and gastric cancer
Original Article

Early palliative care decision is associated with reduced end-of-life healthcare utilization in patients with esophageal and gastric cancer

Pauliina Kitti1 ORCID logo, Nelli-Sofia Nåhls2, Sofia Koivusalo3, Riikka-Leena Leskelä4, Anu Anttonen5, Tiina Saarto6, Outi Akrén6,7, Timo Carpén6

1Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 2Department of Oncology, Vaasa Central Hospital, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland; 3Palliative Center, Turku University Hospital and University of Turku, Turku, Finland; 4Nordic Healthcare Group;5Department of Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 6Palliative Care Center, Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 7Palliative Center, Turku University Hospital and University of Turku, Turku, Finland

Contributions: (I) Conception and design: All authors; (II) Administrative support: T Saarto, O Akrén, T Carpén, A Anttonen; (III) Provision of study materials or patients: T Carpén, T Saarto, RL Leskelä; (IV) Collection and assembly of data: P Kitti, NS Nåhls, S Koivusalo, RL Leskelä, T Carpén; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Pauliina Kitti, MD, PhD. Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland. Email: pauliina.kitti@hus.fi.

Background: Patients with esophageal and gastric cancer have a poor prognosis and high symptom burden. The timing of palliative care decision (PC decision) i.e., discontinuing anticancer treatments and focusing on palliative care, can influence the utilization of healthcare resources, such as hospitalizations and emergency department (ED) visits, at the end of life. The aim of this study was to evaluate how the timing of the PC decision affects hospitalizations and ED visits during the last month of life.

Methods: The retrospective study cohort (n=233) included all patients with esophageal or gastric cancer, treated at the Comprehensive Cancer Center of Helsinki University Hospital, during 2017–2018, and died by the end of 2018. The data on acute healthcare utilization in secondary or tertiary care were extracted from the hospital database. We compared healthcare utilization (ED visits and hospitalizations) based on the timing of the PC decision: early (>30 days before death), vs. no/late (≤30 days before death).

Results: The PC decision was made for 184 patients (79%): in 104 (47%) the decision was early, in 80 (34%) it was late and 49 patients (21%) had no PC decision before death. Median time from PC decision to death was 87.5 days in the early PC decision group vs. 13.5 days in the no/late group, P<0.001. An early PC decision was associated with fewer ED visits (28% vs. 53%, P<0.001) and hospitalizations (20% vs. 67%, P<0.001) in the last 30 days of life compared to the no/late PC decision group. Early PC decision was also associated with more frequent palliative care unit visits (84% vs. 65%, P<0.001), and earlier visits (median 116 vs. 36.5 days before death, P<0.001).

Conclusions: Patients without a timely PC decision are more likely to increase acute healthcare burden through ED visits and hospitalizations during their final month of life. Early PC decisions were also associated with more frequent and earlier access to palliative care services.

Keywords: Esophageal cancer; gastric cancer; palliative care; end of life; healthcare utilization

Submitted Feb 06, 2026. Accepted for publication Apr 24, 2026. Published online May 14, 2026.

doi: 10.21037/jgo-2026-1-0100

Highlight box

Key findings

• In patients with esophageal or gastric cancer, early palliative care decisions (PC decisions), referring to the point at which anticancer treatments are discontinued and the focus shifts to palliative care, were associated with markedly fewer emergency department visits and hospitalizations during the last 30 days of life. Patients with timely decisions also accessed palliative care services earlier and more frequently.

What is known and what is new?

• It is known that patients with advanced esophageal and gastric cancer have a high symptom burden and often rely heavily on acute healthcare at the end of life. Previous research has suggested that timely integration of palliative care may reduce unnecessary interventions.

• This study demonstrates more clearly that the timing of the actual PC decision is important. When the decision was made late (≤30 days before death) or not at all, patients had much higher rates of emergency visits and hospital admissions in their last month of life.

What is the implication, and what should change now?

• Palliative care needs should be identified earlier in the management of esophageal and gastric cancer. The PC decision should be made well before the final month of life. Timely decision-making may reduce the burden on acute healthcare and help patients access palliative services sooner.

Introduction

Esophageal and gastric cancers are associated with poor prognosis (1) and a wide range of complex symptoms (2,3), often resulting from tumor-induced obstruction of the digestive tract and rapid disease progression. Given the complex challenges associated with esophageal and gastric cancer, patients often require comprehensive care that extends beyond conventional oncological treatments.

Palliative care aims to improve the quality of life of patients and their families (4). Evidence from multiple studies highlights its wide-ranging benefits, including better symptom control, fewer hospitalizations and in-hospital deaths, and improved emotional and social well-being (5-12). Despite growing recognition and increased implementation in recent years (13), palliative care remains underutilized, particularly among patients diagnosed with esophageal or gastric cancer (14,15).

To maximize the benefits of palliative care, it should be initiated early and delivered concurrently with anticancer treatments (16,17). However, palliative care is still frequently introduced only after anticancer treatments have been discontinued (18).

In this study, the term “palliative care decision” (PC decision) refers to the point at which anticancer treatments are discontinued, and the focus shifts solely to palliative care, i.e., best supportive care. This decision can substantially influence the care trajectory. Prior studies have shown that patients with a clearly defined palliative intent experience fewer hospital admissions and are less likely to die in hospital settings (19,20).

PC decision differs from early integrated palliative care, as it marks the point at which anticancer treatments are discontinued, and care is focused solely on palliation. Early integrated palliative care, in contrast, is provided alongside ongoing oncological treatment without a decision to stop disease-directed therapy.

In this study, we aimed to assess the impact of the PC decision on acute healthcare utilization in secondary and tertiary healthcare, specifically hospitalizations and ED visits, during the final month of life. Evidence on this topic is scarce for patients with esophageal and gastric cancer, particularly regarding the timing of the PC decision and its association with healthcare utilization. We present this article in accordance with the STROBE reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0100/rc) (21).

Methods

Cohort selection

This retrospective study cohort consisted of all adult patients with esophageal or gastric cancer with at least one contact at the Comprehensive Cancer Center of Helsinki University Hospital during 2017–2018 and who died by the end of 2018. To ensure a minimum look-back period of 3 months, 19 patients who died between January 1st and March 31st, 2017, were excluded. In addition, 16 patients were excluded because their final recorded cancer diagnosis was not esophageal or gastric cancer, indicating that they had previously been diagnosed with these cancers but ultimately died of another malignancy. The final cohort consisted of 233 patients. Patients in this cohort were also part of our previous study, which included all cancer patients and evaluated the impact of an outpatient palliative care clinic visit on healthcare service utilization (22).

Data sources and collection

Data collection included patient gender, primary diagnoses [International Classification of Diseases, 10th revision (ICD-10) codes], palliative outpatient visits and oncology outpatient visits at the Comprehensive Cancer Center of Helsinki University Hospital, date of the PC decision, emergency department (ED) visits in secondary or tertiary care, inpatient episodes in secondary or tertiary care and length of stay, as well as date and age at death. Repeated ED visits were defined as two or more ED visits within the last month of life. Data from primary healthcare services were not available and were therefore not included in the analyses.

The date of the PC decision was defined as the time point at which disease directed anticancer treatments were discontinued and the agreed goal of care was exclusively palliative. This date was identified either by the first recorded Z51.5 palliative care diagnosis code or, when the code was absent, by manual review of clinical documentation. In the Finnish healthcare system, the Z51.5 code is recorded only after a documented decision to stop anticancer therapies has been made and is not used for early or integrative palliative care delivered alongside active oncological treatment.

In addition to examining the timing of the PC decision, we separately assessed the presence of early integrated palliative care. Early integrated palliative care was defined as contact with a palliative care outpatient unit while the patient had still contact with the oncology unit and prior to the documented PC decision to discontinue anticancer treatment. Patients were classified as having received early integrated palliative care if they had at least one palliative care outpatient visit during ongoing oncology care.

Palliative care terms

We measured the effect of PC decision on the utilization of secondary and tertiary healthcare resources. The PC decision was defined as the termination of life-prolonging anticancer treatments and a shift in focus to palliative care, meaning the aim of the treatment was to provide palliative care rather than to prolong life. We compared two groups: (I) patients with early PC decision (more than 30 days before death); and (II) patients with no PC decision or late PC decision (30 days or less before death).

Ethics approval and consent to participate

This study is a retrospective analysis utilizing hospital registry data of patients who died during 2017–2018. The research involved no interventions, as it was entirely based on existing registry information. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board Helsinki University Hospital (HUS/325/2023). Informed consent was waived in this retrospective study.

Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics version 29 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as medians with ranges, and categorical variables as frequencies and percentages. Group comparisons for categorical data were performed using Fisher’s exact test and Pearson’s Chi-squared test. For continuous variables, the Kruskal-Wallis test was applied due to unequal variances between groups. A P value <0.05 was considered statistically significant.

Results

The cohort consisted of 233 patients, of whom 118 (51%) had esophageal cancer and 115 (49%) gastric cancer. The median age at death was 70 years. Patient characteristics are presented in Table 1. The PC decision was made for 184 patients (79%). For 104 patients (47%), the PC decision was made early, >30 days before death, and for 80 patients (34%) the PC decision was made late, ≤30 days before death. For 49 patients (21%), a PC decision was not made.

Table 1

Patient characteristics according to timing of PC decision

Patient characteristics All (n=233) Early PC decision (n=104) No/late PC decision (n=129) P value
Female 66 [28] 27 [26] 39 [30] 0.56
Age (years) 70 [27–99] 73 [46–96] 68 [27–89] <0.001
Primary tumor site 0.48
   Esophageal 118 [51] 52 [50] 66 [51]
   Gastric 115 [49] 52 [50] 63 [49]
PC decision 184 [79] 104 [100] 80 [62] <0.001
Time from PC decision to death (days) 39.5 [0–494] 87.5 [31–494] 13.5 [0–30] <0.001

Data are presented as n [%] or median [range]. PC decision, palliative care decision.

The median time from PC decision to death was 39.5 days. The distributions of the timings of PC decisions are presented in Figure 1.

Figure 1 Timing of PC decision before death. PC decision, palliative care decision.

Of the whole cohort, 42% had ED visits in the last 30 days of life, and 46% were hospitalized. Patients with an early PC decision had fewer ED visits (28% vs. 53%, P<0.001). This corresponded to an absolute risk reduction of 25 percentage points and a relative risk of 0.53 [95% confidence interval (CI): 0.37–0.75; P<0.001]. Similarly, hospitalizations in the last 30 days of life were less common among patients with an early PC decision (20% vs. 67%, P<0.001), representing an absolute risk reduction of 47 percentage points and a relative risk of 0.30 (95% CI: 0.20–0.45; P<0.001), as presented in Figure 2 and Table 2.

Figure 2 Patients with ED visits and hospitalizations during the last 30 days, categorized by timing of PC decision. ED, emergency department; PC decision, palliative care decision.

Table 2

Healthcare utilization according to timing of PC decision

Variables All (n=233) Early PC decision (n=104) No/late PC decision (n=129) P value
Patients with ED visits 30 days before death 98 [42] 29 [28] 69 [53] <0.001
   0 visits 125 [54] 75 [72] 60 [47] <0.001
   1 visit 92 [39] 20 [19] 50 [39] 0.001
   ≥2 visits 16 [7] 9 [9] 19 [15] 0.22
Patients with hospitalizations 30 days before death 108 [46] 21 [20] 87 [67] <0.001
   Number of inpatient days 7 [1–30] 4 [1–21] 7 [1–30] 0.02
   0 inpatient days 125 [54] 83 [80] 42 [33] <0.001
   1–7 inpatient days 59 [25] 15 [14] 44 [34] <0.001
   8–30 inpatient days 49 [21] 6 [6] 43 [33] <0.001
Patients with palliative care unit visit 171 [73] 87 [84] 84 [65] <0.001
   Time from first palliative care unit visit to death (days) 92 [0–525] 116 [7–485] 36.5 [0–525] <0.001

Data are presented as n [%] or median [range]. ED, emergency department; PC decision, palliative care decision.

Early integrated palliative care was applied to 86 patients (37%), who had contact with a palliative care outpatient unit while still attending the oncology unit. The median time from the first palliative care outpatient visit to death was 131 days for patients with early integrated palliative care, while it was 43 days for the rest of the patients (P<0.001).

Discussion

Key findings

This retrospective cohort study examined the effect of PC decision, defined as discontinuation of anticancer treatment and transition to palliative care only. We found that an early PC decision was associated with significantly lower number of acute care hospitalizations and ED visits in patients with esophageal or gastric cancer during their final month of life. In addition, an early PC decision was associated with a higher proportion of patients attending palliative care outpatient services, as well as earlier initiation of these visits. The term “PC decision” differs from “early integrated palliative care”, which refers to the provision of palliative care alongside ongoing oncological treatment without a decision to stop disease-directed therapy.

Comparison with similar research and explanations of findings

The concept of “early palliative care” is defined variably across the literature, with timeframes ranging from 30 days (23-25) to as long as 6 months prior to death (26). In this study, we examined the timing of the PC decision, which refers to the point at which anticancer treatments are discontinued, and the focus shifts to palliative care, regardless of when contact with the palliative care team was established. In our study, an early PC decision was defined as one made at least 30 days before death. This threshold was chosen based on previous studies suggesting that a period shorter than 1 month may be insufficient to deliver the full benefits of palliative care (24,25). Clinically, the 30-day threshold should not be interpreted as an optimal timing, but rather as a minimum period that allows meaningful palliative care engagement. While the association of the PC decision with healthcare utilization was evident when the PC decision was made at least 1 month before death, the median time from the PC decision to death was almost 3 months in the early group, supporting earlier PC decisions.

We found that PC decision was made for the majority (79%) of patients. An early PC decision was associated with more frequent palliative care unit visits. Seventy-three percent of all patients visited palliative care unit, which is consistent with previous data where the proportion of patients with metastatic cancer receiving palliative care services has ranged between 32% and 62% (27-29). The absence of PC decision in 21% of patients suggests that these individuals died while anticancer treatments were still being planned or administered, leaving no opportunity for structured end-of-life care. This may also reflect the oncologist’s approach and awareness of palliative care, as those who make timely PC decisions may be more likely to refer patients to the palliative care team and discontinue cancer treatments at an appropriate stage.

In our study, the PC decision was made relatively late, less than 1 month before death, for every third of the patients. This aligns with a meta-analysis that found that the median time between the start of palliative care and death was only 15 days among patients with cancer (30). Such a brief duration limits the potential advantages of comprehensive, multidisciplinary palliative care. In our cohort, 73% of all patients visited palliative care unit, indicating that specialist palliative care was really implemented. One in three patients had already established contact with the palliative care team during cancer treatment, i.e., early integrated palliative care.

We observed that almost half (46%) of the patients had hospitalizations in the last month, which is in line with a recent meta-analysis reporting a 50% hospitalization rate among patients with cancer in the last month (31). The proportion of patients with ED visits in the last month was 36% in the same meta-analysis, while it was 42% in our study.

Randomized studies have shown that palliative care can reduce hospitalizations and ED visits (5,32) or lower the rate of hospital readmissions (32,33). However, some studies have reported no significant differences in hospitalization rates or ED visits following palliative care interventions (6,7,9,11). In our study, early PC decision was associated with fewer hospitalizations compared to no or late PC decision (20% vs. 67%) and fewer ED visits (28% vs. 53%). Similarly, a national Finnish retrospective study reported an association between palliative care unit contact and reduced use of acute hospital care. In our earlier study including all cancer types, the timing of the palliative care unit visit showed a comparable impact (22). Furthermore, an earlier study from the same hospital demonstrated that both an early PC decision and palliative unit contact were associated with the greatest benefit when combined (24).

In addition to overall hospitalizations and ED visits, we observed that an early PC decision was associated with a lower frequency of hospital stays longer than 7 days in the final month. A similar trend was seen in repeated ED visits, although the difference was not statistically significant. These findings are also clinically relevant, as they resemble previously proposed indicators of overly aggressive care at the end of life. According to Earle et al. (34), multiple ED visits and prolonged hospitalizations (>14 days) are markers of suboptimal end-of-life care in oncology.

Although our analysis focused on the timing of the PC decision, it is also possible that patients with rapidly advancing disease were less likely to have a timely PC decision while simultaneously experiencing higher needs for ED visits or inpatient care.

Strengths and limitations

Strengths of this study include its population-based design and real-world setting, which enhance the applicability of the findings. Limitations include its retrospective design, which inherently restricts causal interpretations and introduces the possibility of reverse causality. Additionally, the dataset was limited to secondary or tertiary hospital records and did not include information from primary healthcare. Furthermore, the data are relatively old, which may affect the generalizability of the findings, as care pathways, documentation practices, and the integration of palliative care into oncology have evolved since the study period. Owing to limitations in the available data, adjusted multivariable analyses could not be performed, limiting the ability to account for important patient- and disease-related factors. Variables such as age, disease burden, performance status, comorbidities, and treatment trajectory may have influenced both the timing of the PC decision and healthcare utilization. Another limitation of this study is the potential misclassification of the PC decision date, as it was partly determined through manual chart review when structured coding with Z51.5 diagnosis code was unavailable.

Conclusions

In this cohort of patients with esophageal and gastric cancer, early PC decisions were associated with reduced use of acute hospital services during the final month of life. Patients with early decisions had fewer hospitalizations and ED visits, and a higher proportion of them attended palliative care outpatient services, with these visits taking place earlier. These results support the importance of timely palliative care planning.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0100/rc

Data Sharing Statement: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0100/dss

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0100/prf

Funding: This work was supported by Helsinki University Hospital (No. Y253S25011) and the Cancer Foundation Finland. Open Access funding provided by the University of Helsinki (including Helsinki University Hospital).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0100/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board Helsinki University Hospital (HUS/325/2023). Informed consent was waived in this retrospective study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Kitti P, Nåhls NS, Koivusalo S, Leskelä RL, Anttonen A, Saarto T, Akrén O, Carpén T. Early palliative care decision is associated with reduced end-of-life healthcare utilization in patients with esophageal and gastric cancer. J Gastrointest Oncol 2026;17(3):132. doi: 10.21037/jgo-2026-1-0100

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