Background: Palliative care during the end of life is associated with greater patient satisfaction, improved quality of life and lower health care costs. Our aim was to study temporal trends of aggressive end of life care and palliative care during terminal hospitalizations in patients with metastatic cancer. We also studied disparities in palliative care in this population. Methods: Adult patients with metastatic cancer who died in the hospital from January 2012 to December 2017 were identified from the Nationwide Inpatient Sample database. Statistical tests for temporal trends of resource utilization were performed. Multivariable logistic regression was used to evaluate predictors of utilization of palliative care. Results: A total of 443,360 patients met the inclusion criteria. Mean age was 66.5 years. Patients were predominantly white (66.6%) with a slight male preponderance (51.9%). Most common primary cancers were lung (27.1%), GI tract (23.6%) and breast (7.6%). Use of chemotherapy and radiation decreased from 3.4% to 2.4% (P< 0.001) and 2.8% to 1.4% (P< 0.001), respectively, over the years. There was no statistically significant change in ICU care (26.6% to 27.2%, P= 0.61) or hospitalization costs ($22k to $23k, P =0.14). There was an increase in use of palliative care, from 45.7% to 61.2% (P< 0.001). Patients were more likely to receive palliative care if they were older, female or treated at teaching hospitals. Blacks and Hispanics were less likely receive palliative care. Compared to patients insured by Medicare, those with Medicaid and private insurance were more likely to be offered palliative care. ICU care and chemotherapy predicted decreased use of palliative services. Conclusions: There is an overall trend towards increased use of palliative services and decrease in chemotherapy and radiation in terminal admissions. There are racial disparities in the utilization of palliative care services, with previous studies attributing knowledge gap, with mistrust of the system in African Americans, and language barriers in Hispanics to be causes for racial disparities. There is a need to increase efforts towards development of palliative care programs in non-academic hospitals.

P value < 0.001 for all variables