Table 3.

Summary of the literature on current utilization of primary palliative care, specialty palliative care, and hospice among patients with HGG.

Author	Country	Number of Centers	Study Type	Number of Participants	Key Findings
Primary Palliative Care
Sizoo (2012) [27]	Netherlands	3	Cross-sectional survey	Physicians and relatives of 155 deceased HGG patients	• 40% of physicians did not discuss end-of-life preferences with patients
Gofton (2012) [40]	USA	1	Retrospective analysis	168 patients with any CNS tumor (101 with HGG)	77% of HGG patients had documented HCP 65% had DNR order 85% had hospice care discussion (68% enrolled in hospice) 12% of patients received specialty palliative care consultation
El-Jawahri (2010) [41]	USA	1	Randomized controlled trial of a verbal narrative of end-of-life treatment options vs verbal narrative plus a video depicting the treatments	50 patients with HGG (23 in intervention arm, 27 controls)	In intervention arm, no participants chose life-prolonging care (vs 26% of controls; p <0.0001) In intervention arm, 91% chose comfort care (vs 22% of controls; p <0.0001) 82.6% of participants reported being ‘very comfortable’ watching the video
Pace (2014) [42]	Italy	1	Pilot intervention of in-home neurology visits, neuro-rehabilitation, psychological support, nursing assistance	848 patients with any brain tumor	61% of patients who died did so at home; 22% died in acute hospitals; 17% died in hospice Significant reduction in hospital readmission rates in final 2 months of life compared to controls (16.7% vs 38%, p <0.001)
Hemminger (2017) [43]	USA	1	Retrospective cohort	117 decedents with GBM	52.1% had any advance directive by the 3rd oncology visit (49.2% health care proxy, 36.1% MOLST, 13.1% living will, 1.6% non-hospital DNR) 26.5% had no advance directive prior to the final month of life 36.8% had a palliative care consult at any point in the disease course
Pompili (2014) [59]	Italy	1	Pilot intervention of in-home neurology visits, neuro-rehabilitation, psychological support, nursing assistance	122 patients with GBM	Among 64 decedents, 53.1% died at home; 34.4% died in a hospice facility; 12.5% died at the hospital Caregivers reported satisfaction with home assistance (97%); nursing (95%); communication (90%); rehabilitation (92%); and social work (85%).
Specialty Palliative Care
Sundararajan (2014) [53]	Australia	Many	Retrospective cohort	678 malignant glioma patients	Patients with high symptom burden 5x more likely to receive palliative care in hospital Patients who receive palliative care are more likely to die at home
Collins (2014) [55]	Australia	4	Retrospective cohort	1160 decedents with PMBT	78% of pts who died during diagnosis admission received a palliative care consult 12% of pts who survived diagnostic admission but died within 120 days received a palliative care consult 5% of patients surviving admission and >120 days received a palliative care consult
Seekatz (2017) [60]	Germany	1	Serial cross-sectional survey	54 patients with GBM	38% of patients chose palliative care when offered within 2 months of diagnosis Patients seen by palliative care had greater improvements in pain and distress than those with no palliative care contact
Hospice
Forst (2017) [56]	USA	1	Retrospective analysis	12437 decedents with malignant glioma	Predictors of hospice enrollment: Older age, female sex, more education, white race, lower median income 77% of enrollees were on hospice >7 days, 89% >3 days
Diamond (2016) [57]	USA	1	Retrospective cohort	160 decedents with PMBT who enrolled in hospice prior to death	23% of decedents enrolled within 7 days of death Late enrollees are often more severely debilitated Risk factors for late referral: Male sex, low socioeconomic status, lack of health care proxy
Dover (2018) [58]	USA	1	Retrospective analysis	1323 deceased Medicare beneficiaries with a malignant brain tumor (383 with PMBT, 940 with SMBT)	24% of PMBT patients had late (1–3 days prior to death) or no hospice care Risk factors for late or no referral: Non-white race, male sex, receipt of any hospital-based care in the final 30 days of life Average decrease of $12,138 in Medicare expenditures in hospice enrollees in PMBT

GBM: Glioblastoma; ACP: Advance care planning; MOLST: Medical orders for life-sustaining treatment; DNR: Do not resuscitate; PMBT: Primary malignant brain tumor; SMBT: Secondary malignant brain tumor.