This multi-year study analyzed end-of-life discussions at a cancer center over four years. On average, 113 patients expired each year, with 60 expiring seven or more days after admission. Lung cancer was the most common cause of death. While palliative care consultations occurred for only 25.5% of patients on average, the study found no correlations between variables like timing of discussions, location, attendance, and palliative care involvement. Without interventions between years, the study could not measure performance improvement directly. Future research would require implementing interventions to gauge their impact over multiple years.

1. -" Cancer is the second most common cause of death in the United States;
In 2014, about 585,720 Americans were expected to die of cancer,
estimating at almost an alarming 1600 people per day (CDC,2015).
-People in our country deny death, believing that medical science can
cure any patient.; Death often is seen as a failure of the health care
system rather than a natural aspect of life (NCI, 2007).
-The importance of why the first end of life discussion should not be last
topic discussed in the diagnoses of serious illness; in addition to the
appropriate time for when this conversations should take place
(American Cancer Society, 2014).
Oncologists admitted that they go along with or nourish patients’ overly
optimistic views of the therapeutic options because they are afraid to
destroy their patients’ hope in alternate treatment and curative options .
(Pfeil, T., Laryionava, K., Reiter-Theil…2014).
INTRODUCTION TO THE PROBLEM
LITERATURE REVIEW
 Completed a data clean up followed by a data analysis using data
collected from medical records, previously recorded by graduate
students
 Filled in gaps in data where necessary
 Created an SPSS file which included a complete data set of
demographics for all patients who expired at Fox Chase Cancer
Center from the years 2009-2012
 Created an SPSS data set of a number of variables to test for
statistical differences and/ or correlations
 Determined at what point in time the end of discussion was given
(timing)
 Determined if any correlations could be made using any of the
variables tested
 Determined which areas need improvement to prevent delays in future
end of life discussions at Fox Chase Cancer Center.
METHODS
During the multi-year End of life study period at the Fox Chase Cancer
on average 113 patients expired in the hospital a year from 2009-2012, 60
of which expired 7 days or greater. The mean age of patients who expired
was 63. During the study it was identified that in the year 2009 Lung
Cancer was the leading cause of death accounting for (22.0%) of the
population, Gastrointestinal Cancer (15.3%), Hematology Cancer
accounted for (11.9%), Head & Neck (11.9%), Genitourinary (10.2%),
Gynecology (8.5%), Breast Cancer (6.8%), Pancreas (3.4%), Liver &
Biliary Tract Cancer (1.7%), Other (8.5%). In the year 2010, Lung
Cancer 11(25.9%), Hematology Cancer (12.1%), Gastrointestinal Cancer
(15.5%), Gynecology Cancer 5 (1.7%), Head & Neck Cancer 5 (8.6%),
Breast Cancer 4 (8.6%), Liver and Biliary Tract Cancer (3.4%), Pancreas
Cancer 2 (6.9%), Genitourinary Cancer (8.6%), Other (1.6%). In the
year 2011, the Primary Cancer Diagnosis: Lung Cancer 11(27.9%),
Hematology Cancer (16.4%), Gastrointestinal Cancer (21.3%),
Gynecology Cancer 5 (8.2%), Head & Neck Cancer (4.9%), Breast
Cancer (8.2%), Liver and Biliary Tract Cancer (4.9%), Pancreas Cancer
2 (3.3%), Genitourinary Cancer (3.3%), Other (1.6%). In the year 2012,
the Primary Cancer Diagnosis 2012: Lung Cancer 11(19.0%),
Hematology Cancer (10.3%), Gastrointestinal Cancer (17.2%),
Gynecology Cancer (6.9%), Head & Neck Cancer (5.2%), Breast Cancer
(15.5%), Liver and Biliary Tract Cancer (6.9%), Pancreas Cancer (6.9%),
Genitourinary Cancer (1.7%), Other (10.3%).
RESULTS
CONCLUSION
As presented, there were no correlations or statistical differences found
between variables presented, as hypothesized at the start of the study.
The biggest drawback of the study was lack of intervention, because no
intervention was set at the end of each year there wasn’t really a way to
measure performance improvement, so instead we searched for
correlations between variables. In order for future research to be
conducted there will need be some type of intervention put into place to
measure improvement over a multi-year period.
REFERENCES
Balaban, R. (2000). A physician’s guide to talking about end-of-life care. J
Gen Intern Med, 15(3), 195-200. doi:10.1046/j.1525-1497.2000.07228.x
Butcher, L. (2010). Health Reform May Push End-of-Life Discussion
Forward; ‘End-of-Life Planning Shouldn't Happen at the End of Life’.
Oncology Times, 32(3), 12. doi:10.1097/01.cot.0000368445.05669.38
Cdc.gov,. (2015). CDC - Cancer - Statistics by Cancer Type. Retrieved 1
April 2015, from http://www.cdc.gov/cancer/dcpc/data/types.htm
Centers for Disease Control and Prevention.(2011). United States Cancer
Statistics. National
Program of Cancer Disease Registries.Retrieved from
http://apps.nccd.cdc.gov/USCS/state.aspx?state=Pennsylvania
Pfeil, T., Laryionava, K., Reiter-Theil, S., Hiddemann, W., & Winkler, E.
(2014). What Keeps Oncologists From Addressing Palliative Care Early
on With Incurable Cancer Patients? An Active Stance Seems Key. The
Oncologist, 20(1), 56-61. doi:10.1634/theoncologist.2014-0031
ACKNOWLEDGMENTS
I would like to thank West Chester University, specifically Dr. Stacie
Metz, PhD and Dr. Gopal Sankaran, MD, DrPH. I would also like to
express my boundless gratitude to my site supervisor, Delinda Pendleton,
BSN, MSN, CPHQ who has become a great mentor in my life, all your
acts of encouragement and words of wisdom served a great purpose. My
dedication and all my hard work thus far is dedicated, In Loving
Memory to the Loves Of My Life, my Grandparents, Dan Mcintosh &
Ruth Ella Stone, my loving angels who take account for my passion for
Medicine and Research; my phenomenal Parents John & LaiVitia Stone,
my Aunt Mary, my lifeline & sisters: Lajon & Tia, Cayana, my little
princess Jim, my brothers: John, Rick, Dywren and Vernon, Thank you
all for believing in me and being the reason I am who I am today. Lastly,
but certainly not least, I want to acknowledge my wonderful best friend
Shaniqua M. Rudd, BS,MS who has accomplished every milestone with
me hand in hand; I thank you for being such a great role model and
always encouraging me to put my best foot forward and conquer the
world!
Debra Bill, PhD, MCHES, Faculty Advisor, College of Health Sciences, West Chester University
Delinda Pendleton, RN, MSN, CPHQ Director Clinical Strategic Initiatives, Site Supervisor, Fox Chase Cancer Center
LaKesha Stone, BS., MPH Candidate
Multi-Year Analysis of End of Life Discussions at an
Oncology Facility:
PROGRAM BACKGROUND
As a medical professional, no matter how many talks you have given to
patients and their families, End of life discussions never seem to get
easier, one has to face the fact no one wants to hear or live with the reality
that they are dying; despite all the pain and suffering one might be
enduring, they still look for a better outcome. According to The National
Cancer Institute Cancer Control Continuum (2007), a patient’s cancer
experience is broken into six phases. The first two phases, prevention and
screening, involve the entire population. The diagnosis, treatment, and
survivorship phases eventually will involve all patients with a diagnosis of
cancer. The end-of-life phase is relevant for patients who have cancers
that cannot be cured but clearly is also relevant to individuals who die of
other causes. (pg 67). During The end of life phase the most critical
components are desirable outcomes and communication. The
communication component is essential when it comes down to doctors
and clinicians being aware of level of pain a patient may be experiencing
and/or any other symptoms, sending and receiving vital information,
keeping the emotions of both patients and clinicians under control,
making life threatening decisions such as: treatment options, palliative or
hospice care options, life sustaining treatments etc. Information exchange
can also be as problematic on both the patient and the clinician side.
Communication with patients with incurable cancer about the transition
from specific anticancer treatment to best supportive care often triggers
ethical challenges around whether or how to address death explicitly and
implies talking about valuable goals for the last weeks or months of life.
It also means dealing with patients’ feelings of hopelessness and
disappointment (Pfeil, T., Laryionava, K., Reiter-Theil, S., Hiddemann,
W., & Winkler, E. 2014). Communicating prognosis has three major
challenges. First, prognoses apply to groups, but the illness trajectory will
be unique for each individual. Second, patients and their families vary in
their wish to know what will happen next. Patients who might tolerate
knowing that they have cancer may not want to know that they are dying.
Third, patients are often discomfited by physician expressions of
uncertainty; consequently, the clinician may feel that he or she has to
assume a posture of expressing more than can be known (Epstein, R., &
Street, R., 2007). The dialogue on hope has similar challenges. Patients
generally want to know the truth. However, when asked, patients with
terminal illnesses often still express hope for a cure (National Cancer
Institute Cancer Control Continuum, 2007). Patients in continuous denial
refuse to accept the truth, and they go to cancer centers with hope in the
‘“name” of the Institution, something will be done, a wonder drug will be
available; they make it difficult for cancer specialized centers because
they still maintain their expectations despite all evidence to the contrary.
Oncologists admitted that they go along with or nourish patients’ overly
optimistic views of the therapeutic options because they are afraid to
destroy their patients’ hope. (Pfeil, T., Laryionava, K., Reiter-Theil, S.,
Hiddemann, W., & Winkler, E. 2014).
Palliative Care Consultation services address the physical, emotional and
spiritual suffering of patients living with chronic and complex illnesses.
Palliative Care is provided by physicians and nurse practitioners to
enhance quality of life, optimize function, relieve symptoms, and support
decision-making. Of those patients who expired, it was found that on
average only (25.5%) of those patients had Palliative Care consultations.
PROGRAM GOALS & OBJECTIVES
Averaging about 115 deaths per year at Fox Chase Cancer Center,
Clinical Strategic Initiatives Director Delinda Pendleton and The Vice
chair of Oncology, Michael Levy, MD decided to begin a study looking
at End of Life Discussions. Each year they would mentor a graduate
student who would collect the data from the previous year from the
medical charts of expired patients. The student would collect a variety
of information regarding expired patient’s end of life of life discussion
i.e. who was in attendance, where the discussion happened, the time
period between the last time treatment was received and the first
discussion etc. This process occurred for about four consecutive years;
however each student only analyzed the data for the year which they
collected.
DISCUSSION
Using the variables presented in the study I began to look for
correlations between variables in a Multi-Year study of end of life
discussions at an Oncology facility. In each of the statistical test I ran I
used a specific variable as the baseline, assuming that another variable
would be influenced by it. The first test I ran with hopes of finding
some type of correlations and/or statically different results was a
correlation Bivariate test in SPSS. Because there was no intervention
between each year the data was collected, the Principal Investigator,
Dr. Levy, predicted that there would be no correlation or statistical
differences found in any of the variables tested, the test proved his
hypothesis to be true. As a result, of this finding no further research
was discussed, nor were there any programs implemented; the
information presented will serve as a baseline to identify opportunities
for improvement.
Because the study was looking at multiple patients and their cases of a
particular disease initially it was thought that it was best for to choose
a case series study. Reason is, in all cases the patients were affected by
cancer and in each case end of life discussions were being examined.
As a result, there was not any pre/post testing, nor were there any
control or experimental groups. Using SPSS software descriptive
analysis tool, I analyzed standard deviation, mean, frequency, and/ or
percent of total for each of the years (2009-2012) the study was
conducted. I then used various charts and graphs to illustrate the
findings specifically the frequencies and percents, in addition to
showing the comparisons and differences in the results of each year
(2009-2012). The data was analyzed by looking at some key points
which included: (1) DNR status during End of life discussion (2)
Attendance during End of Life Discussion (3) Location during End of
Life Discussion (4) timing between Last chemotherapy treatment and
discussion (5) Palliative Care Consultations
PROCEDURES
The goal of this study was to: analyze end-of-life data collected over
a multi-year period to identify trends and opportunities for
improvement, so that future research and programs could be created
to improve timing and End of Life discussion protocols at Fox Chase
Cancer Center