Background: Lymphoma is one of the most common cancers affecting young adults in Sub-Saharan Africa, yet survival outcomes lag far behind those in high-resource settings. A significant contributor to these disparities is treatment abandonment, driven by limited access to essential palliative care support and lack of symptom management medications. This study aimed to assess the feasibility and early uptake of a Symptom Toolkit intervention to support symptom recognition and self-management. Methods: We designed and implemented a novel, low-cost, culturally appropriate Symptom Toolkit into an oncology clinic in Malawi. The toolkit included nurse-delivered patient education and take-home essential therapies targeting high-burden symptoms, including pain, nausea and vomiting, insomnia, gastritis, mucositis, and constipation, with pictorial labels and a journal to record use. Included therapies were selected based on local clinical guidelines and availability. At follow-up visits, a palliative care nurse completed survey assessments and distributed new Symptom Toolkits, noting both symptom occurrence and rates of medication use. Results: A total of 65 patients with lymphoma (median age 39) participated, including individuals with acute lymphoblastic leukemia, Burkitt lymphoma, diffuse large B-cell lymphoma, and Hodgkin’s lymphoma. Across the 602 toolkit reports completed, use of symptom-directed medications increased over time, indicating improved uptake and engagement with the intervention. Conclusions: This pilot intervention demonstrates the feasibility of a nurse-delivered Symptom Toolkit as a means to enhance symptom recognition and self-management in a low-resource oncology setting. Further evaluation of the Toolkit in future studies will assess its impact on symptom burden and quality of life.
Home-based palliative care for patients with advanced heart failure remains challenging because refractory dyspnea and hemodynamic instability often require continuous medical support. Continuous dobutamine infusion is occasionally used to facilitate discharge to home in patients with end-stage heart failure; however, symptom relief with inotropic therapy alone may become insufficient during the terminal stage of illness. Reports describing the combined use of home dobutamine infusion and opioid therapy remain limited, particularly in Japan. We report two elderly patients with advanced heart failure who wished to spend their remaining time at home and were managed with continuous home dobutamine infusion combined with opioid therapy for symptom palliation. Case 1 involved an 84-year-old man with cardiac amyloidosis, severe mitral regurgitation (MR), and low cardiac output syndrome. Despite guideline-directed medical therapy and transcatheter edge-to-edge mitral valve repair, progressive fatigue and heart failure symptoms persisted. Continuous home dobutamine infusion was initiated, and transdermal fentanyl was subsequently added because of worsening dyspnea and discomfort. The patient remained at home and died 99 days after discharge. Case 2 involved a 91-year-old woman with advanced valvular heart disease, severe tricuspid regurgitation, pulmonary hypertension, and recurrent heart failure hospitalization. After temporary stabilization with dobutamine and symptom-oriented treatment, she was discharged home with continuous dobutamine infusion and opioid therapy. Although she died 5 days after discharge, her wish to remain at home was fulfilled. These cases suggest that combined home-based dobutamine infusion and opioid therapy may represent a feasible symptom-oriented palliative care strategy for selected patients with advanced heart failure who strongly prefer home-based end-of-life care. Further studies are needed to clarify patient selection, symptom outcomes, and safety considerations.
Background:Opioid-induced constipation is a practical bowel-management issue when opioids are started for cancer pain, but real-world naldemedine timing and subsequent laxative needs remain variable. Objective:To describe naldemedine initiation timing/context after oxycodone start and early additional laxative adjustment among adults with cancer. Design:Single-center retrospective cohort study using routine clinical records. Setting/Subjects:Adults with cancer pain in a single-center Japanese cancer-care setting who started oxycodone between June 1, 2017, and December 31, 2018, and subsequently received naldemedine. Measurements:Concurrent initiation was naldemedine prescribed as part of the same oxycodone-start prescribing decision; reactive initiation was naldemedine added as a separate prescribing decision after physician-recognized constipation during ongoing oxycodone therapy. The primary outcome was prescription-record-based additional laxative initiation or dose escalation of existing laxatives within 7 days after naldemedine initiation. Secondary outcomes were oxycodone-to-naldemedine interval and diarrhea-related discontinuation within 28 days. Results:Among 101 patients, the primary outcome occurred in 6/31 (19.4%) concurrent and 2/70 (2.9%) reactive cases (p = 0.010). The reactive group had a median oxycodone-to-naldemedine interval of 15 days (interquartile range, 5-83); diarrhea-related discontinuation occurred in 2/31 (6.5%) versus 6/70 (8.6%). Conclusions:Concurrent naldemedine at oxycodone start did not eliminate early additional laxative initiation or escalation. Naldemedine timing should be understood within individualized bowel-management planning, with conventional or rescue laxatives considered when clinically appropriate.
Background:General ward nurses increasingly care for patients with advanced cancer; however, the implementation of evidence-based nursing support remains unclear. Multicenter palliative care unit (PCU) surveys quantified nursing practices for major cancer-related symptoms and caregiver burden using systematically developed item sets; however, findings from PCU settings may not directly generalize to general wards, given differences in staffing, patient populations, and resources. Objectives:To describe the frequency of nonpharmacological nursing for five cancer-related symptoms (pain, dyspnea, nausea/vomiting, constipation, and delirium) and family caregiver burden provided by general ward nurses in Japan. Methods:We will conduct a multicenter, cross-sectional, web-based survey (Jan-Mar 2026) in designated cancer care hospitals nationwide. Registered nurses working in general wards will report their opportunities to provide symptom-related support in the past 12 months and the frequency of specific practices on a 5-point Likert scale. Item sets are based on scoping reviews and prior PCU surveys and will be refined through pretesting with general ward nurses. Primary outcomes are proportions reporting frequent use of each item; analyses will summarize overall and symptom-specific distributions, excluding respondents with no opportunity. Target sample size is 1,300-1,500, estimated using dyspnea and accounting for clustering. Expected Implications:This study will provide nationally representative evidence on nursing support practices in general wards. The findings will inform targeted educational strategies by identifying potential gaps suggested by the observed frequencies of reported practices and enabling contextual interpretation in relation to prior PCU findings, thereby supporting future interventions, strengthening evidence-based palliative care.
Context: Early palliative care can improve end-of-life outcomes, but referrals to palliative care specialists can be delayed in the primary care setting. Objective: This pilot study assessed the effect of a machine-learning algorithm on time to palliative care in a primary care population. Methods: Patients (aged ≥18 years) were eligible if they were empaneled with a primary care provider (PCP) from July 20, 2020, through May 30, 2021. The algorithm evaluated their health records and presented patients who were predicted to have the greatest need for palliative care. Records were then reviewed by palliative care specialists, and patients were randomized in a stepped-wedge fashion to have a referral notification sent to their PCPs if unmet palliative care needs were verified. Time-to-event outcomes were evaluated with Poisson regression models. Results: Of the 127,080 patients evaluated, 934 had their health records presented for review. Some patients were repeatedly presented by the algorithm (total presentations: 1592). In the intervention arm, PCPs were prompted to order a palliative care consultation for 142 patients. The time to 0.1% of the population receiving a palliative care consultation was 60.9 days for the intervention arm versus 71.8 days for the control arm (probability of a shorter time with the intervention, 0.88). Conclusion: A machine-learning algorithm to identify palliative care needs was successfully integrated into a primary care practice. More work is needed to improve the workflow.
Background: Delirium is associated with high mortality and substantial patient distress; therefore, early identification and management are crucial. Among patients with cancer receiving palliative care, delirium is highly prevalent yet often underrecognized by attending physicians. Recently, palliative care for patients with noncancer conditions has gained attention. Nonetheless, the prevalence of delirium and the extent of physician awareness in this population remain unclear. This study aimed to clarify these aspects in noncancer patient populations to raise awareness among physicians and provide insights to improve palliative care delivery. Methods: We retrospectively reviewed 1540 inpatients receiving palliative care at a university hospital in Japan between January 2018 and December 2023. Psychiatric diagnoses, referral reasons, physical diagnoses, and demographic information were analyzed. Results: In the noncancer group, the number of annual referrals to palliative care increased during the study period (from 7 to 66). Both the cancer and noncancer groups were commonly referred for pain, dyspnea, anxiety, insomnia, and delirium. Compared with the cancer group, the noncancer group was more likely to receive a psychiatric diagnosis (45.7% vs. 57.6%) and had a higher prevalence of delirium (12.9% vs. 21.5%). In the noncancer group, the proportion of referrals citing psychiatric symptoms was higher (38.5% vs. 54.2%), whereas the frequency of delirium underrecognition was comparable to that in the cancer group (59.6% vs. 71.0%). Conclusion: Underrecognition of delirium in palliative care settings is a common issue in both cancer and noncancer patient populations. Enhancing physician awareness may improve palliative care quality in these populations.
There is a lack of qualitative and systematic literature exploring the wishes and preferences of adolescents with cancer and their connection to identity and emotional well-being. This scoping review aimed to identify and synthesize existing studies on the end-of-life (EOL) wishes and preferences of adolescents with cancer and examine how these wishes and preferences relate to identity and sense of self. The review was conducted to comprehensively explore and map the EOL wishes and preferences of adolescents with cancer, following the PRISMA-ScR guidelines. The PubMed, CINAHL, and Ichushi-Web (Japan Medical Abstracts Society) databases were searched from their inception until June 3, 2024. In addition, an updated search using PubMed was conducted on October 1, 2025. Overall, 7202 articles were screened, of which 8 were ultimately included. All studies were conducted in North America. Two were qualitative studies using semistructured interviews, revealing that adolescents with cancer expressed preferences related to treatment, place of care, and a desire to spend their final moments peacefully with their families. The remaining six studies were quantitative, including four randomized controlled trials evaluating the family-centered advance care planning for teens with cancer (FACE-TC) and two cross-sectional studies based on secondary analyses of FACE-TC session data. In conclusion, this scoping review highlights the need for further evidence accumulation across diverse regions and the limited number of qualitative studies exploring the EOL wishes and preferences of adolescents with cancer. Although Advance Care Planning tools, such as FACE-TC, have shown promise, challenges remain regarding their feasibility and adaptability in clinical practice. Adolescents’ wishes and preferences are closely tied to their desire to be recognized as whole persons, not defined by cancer, and incorporating this perspective into care may support their identity. Future efforts should emphasize developmentally appropriate support and qualitative research to ensure that adolescent voices are heard and respected.
Background:Dyspnea is one of the most distressing symptoms in patients with advanced cancer. Although systemic opioids are recommended as first-line pharmacologic treatment, 30-50% of patients do not achieve adequate relief. Midazolam is often used for persistent dyspnea despite opioid administration; however, robust evidence supporting its efficacy as a second-line treatment remains limited. Objectives:To evaluate the feasibility of a randomized controlled trial assessing the efficacy and safety of continuous subcutaneous midazolam infusion as second-line treatment for persistent dyspnea despite morphine administration in hospitalized patients with advanced cancer. Methods:A protocol for a multicenter, randomized, double-blind, placebo-controlled feasibility trial (J-SUPPORT2201/JORTC-PAL22) is described. The trial is being conducted at nine sites in Japan. Population:Participants are hospitalized adult patients with advanced cancer who are not receiving active anticancer treatment and who experience dyspnea at rest (Integrated Palliative Care Outcome Scale dyspnea score ≥2) despite continuous morphine infusion. Intervention/Control:Protocol treatment includes standardized morphine escalation plus continuous subcutaneous infusion of midazolam (9 or 6 mg/day for vulnerable patients) or placebo for 24 hours. Measurements:The primary endpoint is feasibility, defined as completion of protocol treatment at 24 hours. Secondary endpoints include dyspnea intensity, anxiety, rescue morphine use, communication, adverse events, and 30-day survival. Conclusions:This feasibility trial will provide methodological insights and preliminary clinical data regarding midazolam as a second-line option for persistent dyspnea despite morphine infusion in patients with advanced cancer and help design future confirmatory trials.
Background:Ensuring a smooth transition from hospital cancer care to home palliative care remains a key challenge, while pharmacist involvement in pre-discharge conferences has traditionally been limited in Japan. We investigated whether coordination by the Board Certified Pharmacist in Palliative Pharmacy (BCPPP) could enhance the extent and quality of pharmacist participation. Methods:In this retrospective descriptive observational study, we examined pre-discharge conferences for patients with advanced cancer, pharmacist participation rates and level of involvement from hospital and community pharmacies, methods of medical narcotics administration, and the rates of short-term readmission from January 2018 to December 2024. The BCPPP-led coordination initiative was initiated in 2022, which comprises of identification of the patients requiring home palliative care, arranging the pre-discharge conferences, support for opioid pharmacotherapy, coaching ward pharmacists, and ensuring the continuity of pharmacotherapy after discharge. Outcomes were compared between periods before (2018-2021) and after the start of interventions by a certified pharmacist (2022-2024). Results:A total of 110 pre-discharge conferences were conducted. The certified pharmacist in palliative pharmacy coordinated collaboration with medical social workers. Pharmacist participation in pre-discharge conferences significantly increased after the intervention (hospital: 9.3% vs. 80.0% [p < 0.01], community pharmacies: 5.3% vs. 54.3% [p < 0.01]). The proportion of pharmacist recommendations focused on discharge planning increased from 35.7% to 73.3% (p < 0.05). The two- and four-week readmission rates did not differ significantly before and after the intervention (two-week: 13.2% vs. 3.0%; four-week: 17.6% vs. 18.2%). Conclusions:Coordination by a certified pharmacist in palliative pharmacy increased pharmacist participation inside and outside the hospital and promoted more proactive involvement in palliative care during pre-discharge planning. Although short-term readmission rates did not significantly change, strengthened collaboration between hospital and community pharmacies may contribute to improved continuity of palliative care during the transition to home.
Background: Palliative care is recognized as a human right within health care; however, access remains limited, especially in low- and middle-income countries. Ethiopia’s health care system faces numerous challenges, including a lack of trained professionals, inadequate policies, and restricted access to essential medications such as morphine. Objective: This exploratory study aimed to examine the cultural, sociological, and psychological barriers to implementing palliative care at Gambo Rural Hospital in Ethiopia. Methods: A qualitative exploratory design was used. Through interviews, perspectives, beliefs, and behaviors related to palliative care were explored, including cultural misconceptions present not only among the general population but also among physicians. Results: The findings revealed important cultural, sociological, and psychological barriers to the implementation of palliative care. Misconceptions and limited understanding of palliative care were identified at both community and professional levels, hindering its acceptance and integration into routine practice. Conclusions: This study underscores the urgent need to integrate palliative care into the training of health care professionals, address cultural and religious factors, and develop community-based palliative care models adapted to local contexts. To improve care, targeted educational initiatives and the incorporation of palliative care into national health strategies are essential to ensure that no patient, particularly those in underserved rural populations such as Gambo, is left to suffer unnecessarily.
Background: Adolescents and young adults (AYAs) with cancer usually receive high-intensity end-of-life care; however, early integration of specialized palliative care can mitigate this. Objective: To examine personalized pain goal (PPG) achievement and palliative care visits for pain management among AYAs with cancer. Design: Cross-sectional survey. Setting/Patients: Consecutively-enrolled outpatients and inpatients with cancer at a university hospital. Measurements: Patient data and self-reported questionnaires were collected from medical records. Results: Among 1226 patients with cancer-related pain, 56 (4.6%) were AYAs. Median pain intensity and PPGs were four each. Pain intensity did not differ significantly between AYAs and older patients ( p = 0.768); however, AYAs reported higher scores as their PPGs compared to older patients ( p < 0.001). AYAs had greater achievement of PPGs (>50%, p = 0.025) and fewer visits to palliative care centers ( p < 0.001). Conclusions: Although AYAs more frequently achieved their PPGs, they also reported comparable pain intensity and had significantly lower referral rates to palliative care centers. These findings suggest that achievement of PPGs alone may not fully capture unmet pain management needs in AYAs and that proactive referral should be considered when pain intensity remains substantial.
Background:Functional somatic syndromes are common causes of noncancer-related pain in patients with cancer. Nonetheless, the prevalence and stress involvement in representative conditions, including myofascial pain syndrome (MPS), tension-type headache (TTH), and migraine (MG), remain insufficiently described. The Armchair Sign is a physical examination maneuver used to evaluate stress-related muscle tension. Objective:To assess stage-specific prevalence and stress involvement of MPS in patients with cancer, with secondary exploratory analyses of TTH, MG, and the association between the Armchair Sign and stress involvement. Design:Multicenter prospective observational study. Setting/Subjects:A total of 1277 patients diagnosed with cancer at three palliative care centers. Results:Cancer stages were survivorship, initial treatment, additional treatment, and best supportive care. Pain was reported by 71.7% (cancer-related, 47.2%; noncancer-related, 43.5%); among them, stress involvement was identified in 60.5%. MPS, TTH, and MG were diagnosed in 12.7%, 7.4%, and 3.5%, respectively. Among those, stress involvement was identified in 48.8% (MPS), 80.0% (TTH), and 71.1% (MG). In the survivorship stage, TTH (17.4%) and MG (7.2%) were more prevalent than in other stages (p < 0.001; p = 0.008). Positive likelihood ratios for the Armchair Sign in relation to stress involvement were 5.05 (95% confidence interval (CI): 2.75-9.26), 6.50 (95% CI: 1.74-24.33), and 6.50 (95% CI: 0.96-44.10) for MPS, TTH, and MG, respectively. Conclusions:MPS and stress involvement were frequent among patients with cancer across cancer stages. TTH, MG, and the Armchair Sign findings should be interpreted as secondary exploratory findings, and they require further validation.
Background: We sought to analyze the effect of a palliative care intervention on quality of life (QoL) in patients with fibrotic interstitial lung disease (fILD). Design: This was a prospective observational study including 14 patients with fILD treated with a bundle of care provided by multidisciplinary specialists in pain and palliative care, a psychologist, physical therapists, and a nutritionist, with all patients initiating 10 mg of morphine sulfate. Measurements at baseline, 30 days, and 90 days included cough, dyspnea, pain, tiredness, nausea, depression, anxiety, sleepiness, appetite, and difficulty sleeping. QoL was recorded using the modified St. George’s Respiratory Questionnaire (SGRQ-1). Change over time in each endpoint was analyzed. Results: Baseline assessment reflected an impaired QoL (median SGRQ-1, 91 points). All symptom scores improved at 90 days, with a statistically significant and clinically meaningful 20-point decrease in the SGRQ-1 ( p = 0.001). Conclusion: Palliative care intervention improves symptom and QoL in fILD.
Background: Patients with cirrhosis who suffer cardiac arrest often undergo cardiopulmonary resuscitation (CPR). However, there is limited data on the effectiveness of CPR in achieving survival or liver transplantation in this population. This study aimed to describe rates of survival after CPR, liver transplantation, and palliative care utilization for hospitalized patients with cirrhosis. Methods: Hospitalized patients with International Classification of Diseases 10th revision codes for cardiac arrest and cirrhosis from October 2017 to December 2022 were included. Patients were excluded if CPR was not performed or if diagnoses were incorrectly coded. Primary outcome was post-CPR survival. Secondary outcomes included rates of transplantation and specialty palliative care utilization. Cox regression models and the log-rank test were used to compare survival in those with and without decompensated cirrhosis. Results: A total of 126 patients were included; 88 had decompensated cirrhosis and 38 had compensated cirrhosis. Overall median survival was < 1 day. Thirty-day survival for compensated and decompensated cirrhosis was 39% and 7.9%, respectively ( p < 0.001). Decompensation was associated with a 2.5-fold increased risk of death within 30 days (95% CI: 1.6–3.0). Two patients reached transplant evaluation and were activated on the transplant wait-list. Specialty palliative care consultation occurred in 25 patients, with most occurring after the CPR event. Discussion: This study demonstrates that post-CPR trajectory differs with presence or absence of hepatic decompensation. Ability to reach liver transplant evaluation after CPR in patients with decompensated cirrhosis is significantly limited by poor survival. Further study is needed to inform goals of care discussions and implementation of primary and specialty palliative care in this population.
Objectives: This study aims to explore the response to anticipatory grief of family caregivers of terminally ill cancer patients in Bangladesh and to identify key factors influencing these grief dimensions. Methods: This study was conducted among 88 family caregivers of the terminally ill cancer patients from three palliative care units of tertiary-level hospitals in Bangladesh. Anticipatory grief dimensions were assessed by the Adult Attitude to Grief scale. Results: The majority of caregivers (75%) reported severe to high levels of emotional vulnerability, suggesting an increased risk of developing complicated grief in the future. Younger caregivers (<= 35 years) were significantly more likely to feel overwhelmed by anticipatory grief. Additionally, caregivers with longer prognostic awareness demonstrated lower resilience and higher emotional vulnerability. However, caregivers' sex and their relationship with the patient were not significantly associated with anticipatory grief dimensions. Conclusion: Family caregivers of terminally ill cancer patients receiving palliative care in Bangladesh experience high levels of anticipatory grief. Early identification of vulnerable caregivers and provision of psychosocial support may enhance resilience and reduce caregiver burden.
Objective: To characterize palliative extubation (PE) as a clinical and ethical process in critically ill patients in a public hospital in Brazil, focusing on timing of palliative care (PC) involvement, shared decision-making, symptom management, and outcomes. Methods: This retrospective cross-sectional study included adult patients who underwent PE between January 2022 and December 2024. Data were obtained from a prospectively maintained institutional PC database and medical records. Variables included demographics, comorbidities, functional status, reasons for intubation, timing of PC consultation, family conferences, opioid use, palliative sedation, and outcomes. Descriptive analyses were performed. Results: Among 447 patients evaluated by the PC team, 122 (27.3%) underwent PE. The mean age was 69.7 years, and 51.6% were female. Half had a Palliative Performance Scale score ≤60 before admission. The mean time from hospital admission to PC consultation was 8.3 days. Family conferences were conducted in all cases (mean: 1.5 per patient), and extubation occurred within three days of the conference in 92.6%. Opioids were used in 77.0% of patients, predominantly morphine; palliative sedation was required in 21.3%, always with midazolam. In-hospital mortality was 91.8%, while 8.2% were discharged. Among deaths, 50% occurred on the same day as extubation, whereas others survived from hours to 31 days. Conclusions: In this cohort, PE was integrated into a structured, family-centered process involving interdisciplinary consensus and individualized symptom management. The variability in survival after extubation supports its interpretation as withdrawal of disproportionate treatment rather than an intervention intended to hasten death, underscoring the importance of early PC integration in intensive care settings.
Background:Bereavement is a known risk factor for depression; however, the prevalence of depression and its associated factors among family members who provided home care for terminally ill cancer patients remains unclear. Objectives:This study aimed to investigate the prevalence of probable depression and associated factors among bereaved family members of cancer patients who died at home in Japan. Design:A multicenter cross-sectional study within a prospective cohort using a self-administered questionnaire survey of bereaved family members. Setting/Subjects:Twenty facilities across Japan participated. Bereaved family members of adult cancer patients who died at home were surveyed. Measurements:Depression was assessed using the Japanese version of the Patient Health Questionnaire-9, with probable depression defined as a total score of ≥ 10. Results:Among 195 bereaved family members, 23 (11.8%; 95% CI: 7.3-16.3%) screened positive for probable depression. Factors significantly associated with depression included unpreparedness for death (OR 11.0; 95% CI 2.8-43.8), caregiver's poor physical condition while providing care (OR 7.4; 95% CI 1.4-39.2), patient dyspnea within one week before death (OR 4.5; 95% CI 1.3-15.6), and use of antipsychotics at the start of home care (OR 6.3; 95% CI 1.2-32.2). Conclusions:A substantial minority of bereaved family members screened positive for probable depression after providing home care. In addition to effective symptom management, especially for dyspnea and addressing neuropsychiatric instability (as indicated by the need for antipsychotics), during home care, ensuring that family members are adequately informed about the patient's condition and addressing their physical well-being may help reduce the risk of depression in bereaved family members.
Background: Extremely premature infants (<28 weeks gestational age) have a greater risk of mortality and, when they survive, higher rates of significant neurological disability and need for medical care. As a result, extremely premature infants and their families often benefit from early involvement of palliative care. Objectives: To identify possible associations between palliative care consultation and length of life, code status, and manner of death of extremely premature versus nonextremely premature neonates. Methods: A retrospective, cohort study of premature infants with a terminal admission at two academic medical centers in the southeastern United States. The primary hypothesis was that extreme prematurity was associated with receipt of a palliative care consultation. Secondary hypotheses examined the association between extreme prematurity with (1) time from admission to death and (2) code status and manner of death. Results: Extreme prematurity was associated with a lower likelihood of a palliative care consultation (p < 0.001) than for older neonates. When consultations occurred, they were often within the final days or hours of life. Females had a 43% higher likelihood of a palliative care consultation than males when controlling for other factors (p < 0.001). Extremely premature infants had lower odds of having an allow natural death versus full code status than older infants (p = 0.008). Conclusions: Infants born extremely premature were less likely to receive palliative care consultation during a terminal admission than older preterm infants. Considering the higher burden of comorbidities and later nature of consultation, extremely premature infants may benefit from earlier and more frequent integration of palliative care.
