Increased hospital-based services for ovarian cancer highlight need for end-of-life plans

Issue: December 10, 2014

Although the receipt of hospice care has increased over time among older patients with ovarian cancer, the rates for ICU admissions, hospitalizations and emergency department visits also increased in this population, according to study results.

The increased use of hospital-based services may indicate the need for end-of-life care plans, researchers wrote.

Alexi A. Wright

“There’s a growing awareness that the use of aggressive, expensive medical interventions at the end of life doesn’t improve patients’ quality of life and may even make it worse,” Alexi A. Wright, MD, MPH, a medical oncologist at Dana-Farber Cancer Institute, said in a press release. “Hospice care — which focuses on intensive symptom management at home — is an attractive option for many people. But unless people make an end-of-life care plan while they’re healthy, spelling out their preferences in advance, these decisions are often made for them or occur in a crisis atmosphere. That may explain why, in this study, we saw an increased use of hospital-based services, even as hospice enrollment increased.”

Wright and colleagues used SEER data and Medicare health care claims to identify 6,956 women aged 66 years or older who were diagnosed with epithelial ovarian cancer between 1997 and 2007. Most patients were non-Hispanic white (86.7%) and had papillary serous carcinoma (71.7%).

Overall, the utilization of hospice services in the last month of life significantly increased from 1997 to 2007 (P˂.001), although the proportion of patients who were enrolled in hospice with 3 or fewer days before death remained steady (P=.2).

Results also showed significantly fewer patients died in hospitals over the study period (P˂.001).

However, average lengths of stay remained stable over time for hospital stays (P=.5) and hospice stays (P=.1).

Over time, a greater proportion of patients were admitted to ICUs (P˂.001), hospitals (P=.005) and emergency departments (P˂.001) during the last month of life, although few patients underwent life-extending procedures (P=.01) or chemotherapy (P=.07).

The rate for inpatient referrals to hospice compared with outpatient referrals increased during the study period (P=.001). Inpatients also were significantly more likely to enroll in hospice within 3 days of death compared with outpatients (24% vs. 16%; OR=1.36; 95% CI, 1.12-1.66).

During the study period, researchers observed increases in the proportion of patients who experienced health care transitions in the last month of life (P=.008), as well as in the mean number of transitions (1.3 vs. 1.6; P=.003). Nearly one of every five patients in the study experienced a health care transition within 3 days of death, results showed.

“Among those who underwent late transitions, nearly two-thirds were transferred from one acute care setting to another or were hospitalized near death,” the researchers wrote. “End-of-life hospitalizations may occur in the setting of uncontrolled symptoms, which require inpatient care. However, a recent study [by Brooks and colleagues] found that oncologists estimated that 20% of hospitalizations among patients with gastrointestinal cancers were potentially avoidable, suggesting that there is room for improvement.”

The trends observed in the current study indicate the benefits and risks of intensive hospital-based care may need to be weighed by patients prior to their last days of life, researchers wrote.

“The earlier people can make plans with their families and physicians, the better they can control the kind of care they receive at the end of life,” Wright said. “Many people want their final days to be a time of legacy building — a time when they can share or build memories with their loved ones — instead of time spent in hospitals or receiving potentially futile medical interventions. Our study points to the extent to which such planning is still needed.”

For more information:

Brooks GA. J Clin Oncol. 2014;32:496-503.
Wright AA. J Clin Oncol. 2014;doi:10.1200/JCO.2014.55.5383.