Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients

Abstract

Objectives To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. Methods Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007–2011 were identified. Statistical analyses included Wilcoxon Mann-Whitney, Chi-square analysis, and multivariate analysis. Results 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30 days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p=<0.001), with a median hospice stay of 18 days before death. Seventy-five percent had an in-hospital DNR and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12 days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378 days prior to death, respectively. Conclusions Many ovarian cancer patients underwent some form of aggressive medical care in the last 30 days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.

How we use hospice: Hospice enrollment patterns and costs in elderly ovarian cancer patients

“…Looking within the larger cohort, we found that among patients who ever enrolled in hospice, black patients were more likely than white patients to unenroll from hospice. This is consistent with data from other disease sites as well ovarian cancer data that suggest non-white patients are less likely to use hospice, despite an overall trend among all races and ethnicities of increasing hospice enrollment over time [10][11][12]15,25,26].…”

“…Acceptance of hospice care is increasing on a national level, including among patients with ovarian cancer, the deadliest gynecologic malignancy [9][10][11][12]. However, disparities still exist among ovarian cancer patients with regard to hospice usage and receiving invasive end of life care [11][12][13][14]. Ovarian cancer patients of minority race and ethnicity and those of lower socioeconomic status have less hospice use and more aggressive end of life care, similar to patterns seen in other disease sites [15,16].…”

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

“…Much of the current literature analyzing end of life resource utilization among gynecologic oncology patients examines outcomes and patterns of care from five or more years ago or focuses on a single disease site. [15–17] Our objective was to identify current disparities in utilization of palliative care and hospice resources among all gynecologic oncology patients.…”

Quality of life, symptoms and care needs in patients with persistent or recurrent platinum-resistant ovarian cancer: An NRG Oncology/Gynecologic Oncology Group study

“…We found improvement in DNR orders between study entry at 28% to 37% at 6 months, however, opportunity for further progress remains. While our study was limited to assessing a DNR order, others have found that the majority of advanced or recurrent ovarian cancer patients do not have any documentation of advance care planning [28]. There continues to be a need for both better understanding of the dynamics of palliative chemotherapy and care between physicians and patients in addressing end-of-life care planning [29].…”