Timing of end-of-life care discussion with performance on end-of-life quality indicators in ovarian cancer

Highlights

• Discussion of end-of-life care occurred late in the disease process and during hospital admissions in ovarian cancer patients.

• Earlier end-of-life discussions are associated with better quality of cancer care.

Abstract

Objectives

(1) To describe the prevalence, timing and setting of documented end-of-life (EOL) discussions in patients with advanced ovarian cancer; and (2) to assess the impact of timing and setting of documented end-of-life discussions on EOL quality care measures.

Methods

A retrospective study of women who died of ovarian cancer diagnosed between 1999 and 2008 was conducted. The following are the EOL quality measures assessed: chemotherapy in the last 14 days of life, > 1 hospitalization in the last 30 days, > 1 ER visit in the last 30 days, intensive care unit (ICU) admission in the last 30 days, dying in an acute care setting, admitted to hospice ≤ 3 days.

Results

One hundred seventy-seven (80%) patients had documented end-of-life discussions. Median interval from EOL discussion until death was 29 days. Seventy-eight patients (44%) had EOL discussions as outpatient and 99 (56%) as inpatient. Sixty-four out of 220 (29%) patients' care did not conform to at least one EOL quality measure. An EOL discussion at least 30 days before death was associated with a lower incidence of: chemotherapy in the last 14 days of life (p = 0.003), > 1 hospitalization in the last 30 days (p < 0.001), ICU admission in the last 30 days (p = 0.005), dying in acute care setting (p = 0.01), admitted to hospice ≤ 3 days (p = 0.02). EOL discussion as outpatient was associated with fewer patients hospitalized > 1 in the last 30 days of life (p < 0.001).

Conclusions

End-of-life care discussions are occurring too late in the disease process. Conformance with EOL quality measures can be achieved with earlier end-of-life care discussions.

Introduction

Evidence suggests that cancer patients frequently receive inappropriately aggressive treatment near the end-of-life (EOL) which may lead to higher resource utilization, increased costs at EOL and decreased quality of life [1], [2], [3], [4], [5], [6]. Aggressiveness of care near the end-of-life has not been associated with increased survival [3]. In fact, in a prospective study of patients with lung cancer by Temel et al., decreased aggressiveness of care was associated with improved survival [4]. Emerging studies describe the relationship between the timing of EOL discussions and aggressiveness of care. For example, in one recent study of patients with stage IV lung and colorectal cancer, an EOL discussion at least 30 days before death was associated with less aggressive care, including administration of chemotherapy in the last 14 days, intensive care unit admissions in the last 30 days and acute care in the last 30 days [7]. This offers compelling insight into how oncologist-directed interventions can increase patient-centered and cost-effective advanced cancer care.

Studies have shown that many cancer patients receive poor-quality care at the end-of-life [8], [9]. To address the need for improved quality of cancer care, the National Quality Forum (NQF) published the following end-of-life quality performance measures, with a lower occurrence representing better quality care: chemotherapy in the last 14 days of life, more than one hospitalization in the last 30 days of life, more than one emergency room visit in the last 30 days of life, intensive care unit (ICU) admission in the last 30 days of life, dying in an acute care setting and admission to hospice for 3 or less days [9]. These measures are intended to reduce overly aggressive treatment and underuse of palliative care services.

Few studies evaluate EOL discussions and quality performance indicators in patients with ovarian cancer. This malignancy is the most lethal gynecologic cancer and fifth leading cause of cancer deaths in the United States. Ovarian cancer is unique compared to many solid tumors, in that some women with ovarian cancer receive all treatment, including surgery, chemotherapy and surveillance, from a gynecologic oncologist. Furthermore, many patients with ovarian cancer will have multiple recurrences as well as successful salvage treatments, and commonly spend years under the care of a single physician. Some studies have shown that physicians who have close long-term relationships with patients often desire to avoid EOL discussions [10], [11]. Given the lethal nature of ovarian cancer, the disease course, and centralized approach to care in gynecologic oncology, there is a critical need to identify and ameliorate deficiencies in end-of-life care for women diagnosed with this disease. The aims of this study were therefore: (1) to describe the prevalence, timing and setting of documented end-of-life discussions in patients with advanced ovarian cancer; and (2) to evaluate the impact of the timing and setting of documented end-of-life discussions on EOL quality care performance measures.