The effect of a multidisciplinary palliative care initiative on end of life care in gynecologic oncology patients

118 Background: Patients with advanced cancer have high rates of hospitalizations as a result of their oncologic care. Furthermore, these patients receive aggressive end of life care despite evidence that aggressive end of life care does not improves quality of life or outcomes for patients and is associated with worse bereavement adjustment for caregivers. The American Society of Clinical Oncology has endorsed several indicators of aggressive end of life care, but most striking is intensive care unit (ICU) admission within 30 days before death. Methods: Adult oncology patients who died within 30 days of hospitalization and/or admitted to the ICU from 10/2018-3/2019 at an academic medical center were evaluated. The cohort was identified using ICD-10 codes, EMR systems support, and manual chart review. Patient demographic data, cancer type, stage, line of therapy, code status, advanced care plan, prior admissions as well as other clinical characteristics were collected. Results: In total, 180 patients were included for analysis; 106 of which were admitted to the ICU. Of patients admitted to the ICU, 58 patients died (54.7%). Mean ECOG performance status was 1.24. Average number of admissions 3 and 6 months prior to death was 0.71 and 1.26. Thirty six percent of patients were on first or second-line chemotherapy. 41.37% of patients who died in the ICU had prolonged length of stay (>1 week). Only 34.48% were known to palliative care prior to admission and 12.06% of patients had advanced care plans in place at time of hospitalization. Palliative care was consulted on 32.75% of patients who died in the ICU. Ninety Three percent had their code status changed prior to death. Conclusions: Despite established recommendations to support otherwise, at our institution there continues to be high utilization of ICU care near the end of life. Previous admissions and ECOG status are poor predictors of death in this cohort. The majority of patients had relapsed and refractory disease. There was a low rate of advanced care planning or palliative care involvement prior to the patient’s hospitalization. Further interventions are underway to improve end of life planning in order to improve our quality of care.

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How equal is end-of-life care among gynecologic oncology patients?

Gynecologic Oncology ◽

10.1016/j.ygyno.2015.01.490 ◽

2015 ◽

Vol 137 ◽

pp. 194-195

Author(s):

J.S. Taylor ◽

A.J. Brown ◽

L.S. Prescott ◽

C.C.L. Sun ◽

L.M. Ramondetta ◽

...

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Gynecologic Oncology ◽

Life Care ◽

Oncology Patients

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Assessing the Unique Experiences and Needs of Muslim Oncology Patients Receiving Palliative and End-of-Life Care: An Integrative Review

Journal of Palliative Care ◽

10.1177/0825859718800496 ◽

2018 ◽

Vol 34 (1) ◽

pp. 52-61 ◽

Cited By ~ 2

Author(s):

Carolina Gustafson ◽

Mark Lazenby

Keyword(s):

Palliative Care ◽

End Of Life ◽

End Of Life Care ◽

Care Delivery ◽

Data Extraction ◽

Integrative Review ◽

Life Care ◽

Oncology Patients ◽

Care Models ◽

Patient Care Delivery

The objective of this review was to detail the experiences of Muslim oncology patients receiving palliative and end-of-life care and identify where gaps in the providing of culturally aware care occur. We also sought to examine ways in which providers could be better educated on the needs of Muslim patients at the end-of-life and identify barriers Muslims faced when being treated with hospice and palliative care models developed for non-Muslim populations. We conducted a search in April 2018 in the National Library of Medicine and CINAHL databases using the search terms “palliative care,” “Muslim,” and “cancer.” Included were articles with focuses on adult Muslims with palliative and end-of-life care experiences. We then followed the PRISMA guidelines for an integrative review and used a data extraction matrix to identify 20 papers that met the inclusion criteria of the review. We identified four major themes patient experiences, patient care delivery suggestions, Muslim provider experiences, and definitions of death, present in all 20 papers of the review. Each of the included papers was categorized based on the dominant theme in the paper. This review ultimately found that the care provided to Muslim patients is subpar for the standard of culturally competent care and that the needs of Muslim patients at the end-of-life, as well as the needs of their families, are not being met. Moving forward further research on this topic is needed with a particular focus on examining the experiences of terminally ill Muslim patients receiving treatment in non-Muslim majority settings.

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Managing symptoms when “the first step or two isn’t working”: Provider and patient perceptions of the role of specialty palliative care in symptom management in gynecologic oncology.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.31_suppl.47 ◽

2014 ◽

Vol 32 (31_suppl) ◽

pp. 47-47

Author(s):

Carolyn Lefkowits ◽

Dio Kavalieratos ◽

Janet Arida ◽

Winifred Teuteberg ◽

Heidi Donovan ◽

...

Keyword(s):

Palliative Care ◽

End Of Life ◽

Care Provider ◽

Symptom Management ◽

End Of Life Care ◽

Gynecologic Oncology ◽

Gynecologic Cancer ◽

Life Care ◽

Multiple Symptoms

47 Background: Our objective was to describe gynecologic oncology (GO) providers’ and patients’ knowledge, attitudes and preferences related to utilization of specialist palliative care (SPC) for symptom management. Methods: Semi-structured qualitative interviews with 19 GO providers (7 physicians, 7 advanced practice providers, 5 nurses) and 30 patients with advanced or recurrent gynecologic cancer from an academic medical center. Key interview domains include: patient symptoms, perceived role of oncology team regarding symptom management, familiarity with SPC, and barriers and facilitators to utilization of SPC for symptom management. Qualitative analysis is underway. Results: 19 provider interviews and 29 patient interviews were completed. Preliminary findings indicate shared beliefs between providers and patients, including an overall willingness to involve SPC in symptom management. Although providers felt comfortable initially managing common symptoms, they expressed interest in involving SPC for complex or multiple symptoms. Patients do not expect their GO providers to manage severe symptoms, noting concerns of complex symptom management as burdensome to the GO team. Barriers to involving SPC in symptom management included: patients’ perceptions of SPC as synonymous with end-of-life care, and logistical issues (e.g., scheduling and transportation). When a distinction was drawn between SPC for symptom management and end-of-life care, patients were uniformly open to seeing SPC for symptom management. Conclusions: GO patients’ and providers’ perception of the role of oncology providers in symptom management is consistent with the concept of a primary palliative care provider, delivering initial management of common symptoms. Specialty palliative care services are seen as complementary to the GO providers’ skillset and particularly useful for severe or multiple symptoms. Implications include the importance of ensuring that oncology provider training includes dedicated attention to symptom management to enable them to fulfill the role of primary palliative care provider.

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Evaluating risk characteristics for patients who die within 30 days of hospitalization.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.161 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 161-161

Author(s):

Christine Kurian ◽

Jennifer Hong ◽

Andrea Sweeney ◽

Laetitia N'Dri ◽

Karen Walsh ◽

...

Keyword(s):

Palliative Care ◽

Logistic Regression ◽

Length Of Stay ◽

End Of Life ◽

End Of Life Care ◽

Nutrition Status ◽

Care Planning ◽

Life Care ◽

Oncology Patients ◽

Code Status

161 Background: Advanced cancer patients often receive aggressive end of life care despite questionable benefit. As a result, there are ongoing efforts to improve end of life care and coordinate palliative care supportive services. This study is an expansion of a previous study performed examining descriptive data in a population of oncology patients who died within 30 days of admission. Here, we compare patients who died within 30 days of admission against those who survived to evaluate differences in patient characteristics and healthcare utilization. Methods: Adult oncology patients who were admitted from 10/1/2018-3/30/2019 at an academic medical center were evaluated. Two groups of patients were studied–oncology patients who died within thirty days of admission and those who survived. The patients were selected using ICD-10 codes, EMR systems support, and manual chart review. Additionally, we examined demographic (i.e. gender, ethnicity, cancer diagnosis) and clinical characteristics (i.e. level of care, code status, previous palliative care consult, palliative care consult in the hospital, nutrition status, clinical trial status, advance care planning, hospice enrollment). Statistical analysis included chi-squared and ANOVA tests, and logistic regression models. Results: A total of 267 patients were included in the analysis. For all patients in the study, 38% had a change in code status during their admission. 26% of patients had palliative care involvement and 23% were known to palliative care prior to admission. Twenty three percent spent the duration of their admission in the ICU for their end of life care. Significant mortality-level variation was found compared to overall mean number of admissions for the past 6 months (ANOVA F=25.3, p<0.0001). We conducted a logistic regression and adjusted for ethnicity, number of admits in the last 6 months, and length of stay to identify the outcome of patients who died within 30 days of admission vs. those who did not. Factors associated with increased odds of mortality included the number of admits in the last 6 months (OR 1.753, 95% CI: 1.397-2.200). Length of stay did not increase one’s odds for mortality (OR 0.989, 95% CI: 0.965-1.014). Conclusions: Low utilization of palliative care and advanced care planning was seen widely in both populations. Previous hospitalization in the last 6 months was a predictor of mortality in this patient population.

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Dying well: How equal is end of life care among gynecologic oncology patients?

Gynecologic Oncology ◽

10.1016/j.ygyno.2015.12.012 ◽

2016 ◽

Vol 140 (2) ◽

pp. 295-300 ◽

Cited By ~ 13

Author(s):

Jolyn S. Taylor ◽

Alaina J. Brown ◽

Lauren S. Prescott ◽

Charlotte C. Sun ◽

Lois M. Ramondetta ◽

...

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Gynecologic Oncology ◽

Life Care ◽

Oncology Patients

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End-of-life care planning in patients with recurrent gynecologic cancers.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.e20648 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. e20648-e20648

Author(s):

Nathan L Jones ◽

Shelley L Galvin ◽

Timothy J Vanderkwaak ◽

David J. Hetzel ◽

Cameron Blair Harkness ◽

...

Keyword(s):

Ovarian Cancer ◽

Palliative Care ◽

End Of Life ◽

Median Duration ◽

End Of Life Care ◽

Gynecologic Oncology ◽

Care Plan ◽

Life Care ◽

Do Not Resuscitate ◽

Gynecologic Cancers

e20648 Background: Gynecologic oncologists and associates must provide appropriate, acceptable, and patient-centered end-of-life care. Most women with terminal gynecologic cancers do not have do-not-resuscitate (DNR) orders upon hospital admission and many do not receive effective palliative care. Our objective was to assess quality care indicators involving end-of-life care among gynecologic oncology patients treated at our institution. Methods: An IRB-approved retrospective chart review was performed on all patients with recurrent gynecologic cancers and terminal diagnoses who died from January 2009 through October 2012. Data included intervals to death from: diagnoses, DNR status, Hospice/Palliative Care Medicine (HPCM) involvement, and other factors related to end-of-life care. Chi-squared and discriminate analyses were utilized. Results: Complete data were available for 130 of 345 (37.7%) patients. Disease sites included cervix 28 (21.5%), uterine 37 (28.5%), ovarian 51(39.2%), and vaginal/vulvar 14 (10.8%). Median age at diagnosis and death was 63 and 65 years. Relative to death, diagnoses occurred at a median of 1.65 (0.05-32) years prior. 83 (63.8%) patients were DNR at their last hospitalization, 84(64.6%) had HPCM involvement, and 18(13.8%) had an advance care plan. When HPCM was involved, 83.3% were DNR as compared to 28.3% without involvement (p=0.0001). Patients were also significantly more likely to have DNR status with diagnosis of ovarian cancer and as the duration of time between diagnosis and death increased (p=0.0001). The provider obtaining DNR was most often faculty over residents or HPCM (60.2%, 27.7%, 12%). DNR status was declared by 57 (68.7%) patients and 26 (31.3%) power of attorneys. Median duration from DNR to death was 14 days (0-308) and median duration from HPCM involvement to death was 22 days (0-391). Conclusions: DNR status is associated with ovarian cancer, HPCM involvement, and increasing time from diagnosis to death. Earlier intervention from providers or HPCM could allow for greater patient autonomy and fewer interventions at end-of-life.

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