-" 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

CONCLUSIONAs 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.

REFERENCESBalaban, 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

ACKNOWLEDGMENTSI 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.

DISCUSSIONUsing 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