Post on 31-Dec-2015
Chemotherapy AuditChemotherapy Audit Audit of patients who died within three Audit of patients who died within three
months of their last dose of chemotherapy months of their last dose of chemotherapy at Airedale General Hospital at Airedale General Hospital
The records of 50 patients who had died within The records of 50 patients who had died within three months of their last dose of chemotherapy three months of their last dose of chemotherapy were identified and then examined according to a were identified and then examined according to a proforma.proforma.
The aim was to have an estimate of the incidence The aim was to have an estimate of the incidence of this occurrence, to audit record keeping, of this occurrence, to audit record keeping, decision making, and to try and assess if decision making, and to try and assess if chemotherapy had been appropriately given.chemotherapy had been appropriately given.
Chemotherapy AuditChemotherapy Audit Reviewing the literature there is very little information on Reviewing the literature there is very little information on
what the expected percentage of cancer patients who die what the expected percentage of cancer patients who die within three months of chemotherapy is.within three months of chemotherapy is.
A study from Massachussetts in 1996, looking at a A study from Massachussetts in 1996, looking at a population of 8,000 cancer patients found thatpopulation of 8,000 cancer patients found that
41% of patients received chemotherapy in the last year of 41% of patients received chemotherapy in the last year of lifelife
33% in the final 6 Months33% in the final 6 Months 25% in the final 3 months25% in the final 3 months 9% in the last month9% in the last month They tried to assess if chemotherapy had been given They tried to assess if chemotherapy had been given
appropriately dividing patients in to groups of tumours appropriately dividing patients in to groups of tumours thought to be sensitive to chemothotherapy and those not . thought to be sensitive to chemothotherapy and those not . They found no difference in rates of treatment givenThey found no difference in rates of treatment given
Chemotherapy AuditChemotherapy Audit
No comparable data could be found for the No comparable data could be found for the UK or more recent.UK or more recent.
The population served by AGH is The population served by AGH is approximately 205,000approximately 205,000
Approx Number of Deaths from Cancer per Approx Number of Deaths from Cancer per year year
Craven : 145Craven : 145 Airedale : 341Airedale : 341 Pendle : 47Pendle : 47 Total : 533Total : 533
Chemotherapy AuditChemotherapy Audit 48 sets of notes found and audited48 sets of notes found and audited Covering a period from 4/4/02 to 31/01/03 Covering a period from 4/4/02 to 31/01/03
approximately 10 months All patients were approximately 10 months All patients were receiving palliative chemotherapy not adjuvantreceiving palliative chemotherapy not adjuvant
Equivalent to 1.2 X 48 deaths per year = 58 Equivalent to 1.2 X 48 deaths per year = 58 deaths per year within 3 months of deaths per year within 3 months of chemotherapy. chemotherapy.
11% of patients dying from cancer had 11% of patients dying from cancer had chemotherapy within the last 3 months within chemotherapy within the last 3 months within AGH catchment area.( This does not include AGH catchment area.( This does not include private patients or those receiving chemotherapy private patients or those receiving chemotherapy else where)else where)
AuditAudit
SexSex Female : 26(54%)Female : 26(54%) Male : 22 (45%)Male : 22 (45%) Age RangeAge Range 41 - 5041 - 50 4 (8%)4 (8%) 51 - 6051 - 60 11(23%)11(23%) 61 - 7061 - 70 13(27%)13(27%) 71 - 8071 - 80 17(36%)17(36%) 81 – 9081 – 90 3 (6%)3 (6%)
Cancers treated over the last 5 Cancers treated over the last 5 years 2000 to Oct 31st 2004years 2000 to Oct 31st 2004
Sex Ratio F 688(61%) M 434(39%)Sex Ratio F 688(61%) M 434(39%)Age RangesAge Ranges 0-30 7 (.6%)0-30 7 (.6%) 31-40 41 (4%)31-40 41 (4%) 41-50 117 (10%)41-50 117 (10%) 51-60 299 (27%)51-60 299 (27%) 61-70 323 (29%)61-70 323 (29%) 71-80 289 (29%)71-80 289 (29%) 81-90 43 (4%)81-90 43 (4%)
All Trust Patients
Oncology Deaths 0304
monthyeardisch Total
Apr-03 2
May-03 3
Jun-03 1
Jul-03 8
Aug-03 5
Sep-03 3
Oct-03 5
Nov-03 2
Dec-03 2
Jan-04 5
Feb-04 6
Mar-04 8
Grand Total 50
Oncology Inpatient Deaths 03/04Oncology Inpatient Deaths 03/04(All Deaths : 830)(All Deaths : 830)
Oncology Deaths Average
Length of Stay(DAYS) 0304
monthyeardisch Total
Apr-03 9.0
May-03 12.7
Jun-03 11.0
Jul-03 11.3
Aug-03 7.8
Sep-03 7.0
Oct-03 11.2
Nov-03 7.5
Dec-03 10.5
Jan-04 9.8
Feb-04 14.5
Mar-04 12.0
Grand Total 10.8
Diagnosis of Patients who died within 3 Diagnosis of Patients who died within 3 months of their chemotherapymonths of their chemotherapy
Cancer DiagnosisCancer Diagnosis Number of Patients (days from last Number of Patients (days from last chemotherapy to chemotherapy to
death)death)
Non small cell lungNon small cell lung 14 (4, 10, 16, 21, 23, 26, 26, 34, 38, 46, 14 (4, 10, 16, 21, 23, 26, 26, 34, 38, 46, 49,54, 73,84)49,54, 73,84) Colo-RectalColo-Rectal 9 (9, 18, 21, 21, 23, 36, 41, 55, 58)9 (9, 18, 21, 21, 23, 36, 41, 55, 58)
Ca PancreasCa Pancreas 7 (1, 8, 9, 11, 15, 20, 59)7 (1, 8, 9, 11, 15, 20, 59)
Small Cell Ca LungSmall Cell Ca Lung 5 (2, 4, 5, 37, 5)5 (2, 4, 5, 37, 5)
Breast CancerBreast Cancer 5 (9, 13, 27, 42, 5)5 (9, 13, 27, 42, 5)
OvarianOvarian 4 (13, 27, 40, 4)4 (13, 27, 40, 4)
BladderBladder 1 (12)1 (12)
Diagnosis *2000 *2001 *2002 *2003 *2004 Total
Breast 63 72 51 57 88 331
Colon 25 35 24 23 33 140
NSCCL 13 23 28 16 43 123
SCLC 19 22 13 19 20 93
Ovary 10 12 14 5 40 81
Rectal 9 16 14 13 25 77
Pancreas 8 5 7 11 17 48
Bladder 5 8 11 14 6 44
Gastric 9 9 2 5 17 42
Oesophageal 6 11 5 4 11 37
Adeno 3 8 5 8 8 32
Prostate 1 1 0 6 9 17
Mesothelioma 0 3 1 3 7 14
Unknown 4 1 5 1 1 12
Endometrial 0 0 0 1 3 4
Malignant Melanoma 2 0 1 0 1 4
Cholangio 1 0 1 0 2 4
Peritoneal 0 0 2 1 1 4
Renal 1 1 1 0 0 3
Others 12
Total 1122
Chemotherapy
Given by
Diagnosis
2000 to
Oct 31st 2004
Diagnosis of Patients who died within 1 Diagnosis of Patients who died within 1 month of their chemotherapymonth of their chemotherapy
Cancer DiagnosisCancer Diagnosis Number of Patients (days Number of Patients (days
from last chemotherapy from last chemotherapy to death)to death)
Non small cell lungNon small cell lung 77 (4, 10, 16, 21, 23,26, 26) (4, 10, 16, 21, 23,26, 26) Ca PancreasCa Pancreas 66 (1, 8, 9, 11, 15, 20) (1, 8, 9, 11, 15, 20) Colo-RectalColo-Rectal 55 (9, 18, 21, 21, 23) (9, 18, 21, 21, 23) Small Cell Ca LungSmall Cell Ca Lung 33 (2, 4, 5) (2, 4, 5) Breast CancerBreast Cancer 33 (9, 13, 27) (9, 13, 27) OvarianOvarian 22 (13, 27) (13, 27) BladderBladder 11 (12) (12)
Diagnosis of Patients who died within 1 Diagnosis of Patients who died within 1 week of their last dose of chemotherapyweek of their last dose of chemotherapy
Cancer DiagnosisCancer Diagnosis Number of Number of PatientsPatients
(days from last (days from last chemotherapy to death)chemotherapy to death)
Small Cell Ca Lung Small Cell Ca Lung 3 (2, 4, 5)3 (2, 4, 5) Non Small Cell Lung Non Small Cell Lung 1 (4)1 (4) PancreasPancreas 1 (1)1 (1)
Diagnosis of Patients who died within 1 to 2 Diagnosis of Patients who died within 1 to 2 weeks of their last dose of chemotherapyweeks of their last dose of chemotherapy
Cancer DiagnosisCancer Diagnosis Number of Patients (days from last Number of Patients (days from last
chemotherapy to death)chemotherapy to death)
PancreasPancreas 3 (8, 9, 11) 3 (8, 9, 11) BreastBreast 2 (9,13) 2 (9,13) ColonColon 1 (9 ) 1 (9 ) BladderBladder 1 (12) 1 (12) Non Small Cell Ca Lung 1 (10)Non Small Cell Ca Lung 1 (10) OvaryOvary 1 (13) 1 (13)
Chemotherapy Regimen and DeathChemotherapy Regimen and Death within three months within three months
Regime Regime Number of Deaths within 3 monthsNumber of Deaths within 3 months
VinorelbineVinorelbine 66 5 FU and Folinic Acid5 FU and Folinic Acid 55 (Mitomycin,Vinblastin,(Mitomycin,Vinblastin, 55 Cisplatin)Cisplatin) ECFECF 55 CarboplatinCarboplatin 44 GemcitabineGemcitabine 33 (Doxorubicin,Vincristine(Doxorubicin,Vincristine 33 +/-Cyclophosphamide)+/-Cyclophosphamide) (Vinorelbine,Cisplatin)(Vinorelbine,Cisplatin) 22 Liposomal DoxirubicinLiposomal Doxirubicin 22 ExatecanExatecan 22 IrinotecanIrinotecan 22 OthersOthers 99
Number of patients NeutropenicNumber of patients NeutropenicNear to or on day of deathNear to or on day of death
5 patients were neutropenic at death 5 patients were neutropenic at death
Patient No DiagnosisPatient No Diagnosis Last Chemo Last Chemo Days from Days from deathdeath
17 Pancreas17 Pancreas ExatecanExatecan 8 8 44 NSCCL44 NSCCL VinorelbineVinorelbine 1010 42 Ovary42 Ovary Lip DoxorubicinLip Doxorubicin 1313 5 Colorectal5 Colorectal 5FU + Folinic acid 5FU + Folinic acid 1818
26 Breast26 Breast FECFEC 62 62 6 other patients were neutropenic within 2 weeks of death 6 other patients were neutropenic within 2 weeks of death
but their counts had risen prior to deathbut their counts had risen prior to death
Deaths Within Three Months of Last Dose of Chemotherapy Over a 10 Month Period from
04/04/02 to 31/01/03
4
9
7
6
1
7
2
1
3
0
2
1
0
1
2
3
4
5
6
7
8
9
10
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12
Weeks since last chemotherapy
Nu
mb
er o
f P
atie
nts
Time from first ever Chemotherapy to DeathIn Patients who died within three months of their last
chemotherapy
0
2
4
6
8
10
12
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month10
Month11
Month12
Greaterthan 1year
Time in Months
Nu
mb
er o
f P
atie
nts
Series1
Age Range of Patients Who Died Within Three Months of Receiving Chemotherapy
4
11
13
17
3
0
2
4
6
8
10
12
14
16
18
41-50 yrs 51-60 yrs 61-70 yrs 71-80 yrs 81- 90 yrs
Age
Nu
mb
er o
f P
atie
nts
Series1
Age of Patient and number of Days from Last Chemotherapy Until Death
0
10
20
30
40
50
60
70
80
90
0 10 20 30 40 50 60 70 80 90
Age Of Patient
Nu
mb
er o
f d
ays
fro
m la
st c
hem
oth
erap
to
dea
th
Series1
Number of Days spent in Hospital during the patients last 13 weeks before death
1
13
12
9 9
0
2
4
6
8
10
12
14
0 Days 1-7 Days 8 - 14 Days 15 - 31 Days > 31 Days
Number of Days
Nu
mb
er o
f P
atie
nts
Series1
Patients Performance Status Meausured at Last Medical Contact
Yes 42%(20)
No 48%(23)
Not Recorded 10%(5)
Evidence in the notes of discussion with the patient about stopping chemotherapy (N=48)
Yes42%
No52%
Not Recorded6%
Had a formal descision to stop chemotherapy been recorded in the notes (N = 48)
Yes33%
No61%
Not Recorded6%
Was Palliative Care Team Involved with the Patient
Yes52%
No33%
Not Recorded15%
DNR Recorded in The Notes
Yes57%
No43%
Recent Performance Status Recorded
Yes45%
No55%
Patients Views On Treatmant Noted
Yes64%
No36%
At Last Medical Assessment Disease Considered To Be
61%
6%
17%
10%6%
Progressive Disease
Responding to Treatment
Stable Disease
To Early to Say
Not Recorded
Recent data On Tumour Markers
Yes73%
No27%
Recent Radiology
Yes64%
No36%
ConclusionsConclusions 1 1
All patients were having palliative All patients were having palliative chemotherapychemotherapy
NSCLC and Pancreatic cancers high riskNSCLC and Pancreatic cancers high risk Recording of information not always Recording of information not always
sufficientsufficient No clear documentation of decision No clear documentation of decision
makingmaking This does not mean appropriate decisions This does not mean appropriate decisions
were not made but they were not were not made but they were not recordedrecorded
Conclusions 2Conclusions 2 Difficult to assess appropriateness of Difficult to assess appropriateness of
chemotherapy as information not therechemotherapy as information not there Profroma needed to capture informationProfroma needed to capture information CPR decisions need to be made more CPR decisions need to be made more
routinelyroutinely Deaths within 3 weeks should be routinely Deaths within 3 weeks should be routinely
auditedaudited Need to compare results with other unitsNeed to compare results with other units Need for separate audit of outcomes from Need for separate audit of outcomes from
neutropenic sepsisneutropenic sepsis Place of death more likely to be in hospitalPlace of death more likely to be in hospital
Conclusions 3Conclusions 3
Need for MDT discussion for patients Need for MDT discussion for patients with poor performance statuswith poor performance status
? Review with each cycle? Review with each cycle Consent clinicConsent clinic Survey of patients/carer’s viewsSurvey of patients/carer’s views Role of Palliative care team in these Role of Palliative care team in these
decisions?decisions?
Role of Palliative CareRole of Palliative Care
Palliative Chemotherapy becoming more Palliative Chemotherapy becoming more common. e.g. Lung (NSCCL), Pancreas, 2common. e.g. Lung (NSCCL), Pancreas, 2ndnd 33rdrd 4 4thth 5 5thth line Rx for breast, ovary, line Rx for breast, ovary, colorectal.colorectal.
Some evidence it can improve quality of Some evidence it can improve quality of lifelife
Balance between benefits and burdens Balance between benefits and burdens becoming more difficult to assess.becoming more difficult to assess.
Needs ongoing research and collaborationNeeds ongoing research and collaboration3333
Possible Proforma 1Possible Proforma 1
Palliative chemotherapy assessment for ongoing Palliative chemotherapy assessment for ongoing treatmenttreatment
Should treatment continue, stop or be changedShould treatment continue, stop or be changed Performance status (last 4)Performance status (last 4) QOL question (last 4)QOL question (last 4) Tumour markers last 4 results (or graph)Tumour markers last 4 results (or graph) Recent radiology Summary of findingsRecent radiology Summary of findings Disease respondingDisease responding StableStable ProgressiveProgressive
Possible Proforma 2Possible Proforma 2
Side effects from treatmentSide effects from treatment Recent episodes of Recent episodes of
Neutopenia/thrombocytopenia/anaemiaNeutopenia/thrombocytopenia/anaemia Dose reduction consideredDose reduction considered Patients view on continued treatmentPatients view on continued treatment KeenKeen
AmbivelentAmbivelent Not keenNot keen
CPR statusCPR status
Possible Proforma 3Possible Proforma 3
Overall aim of treatmentOverall aim of treatment Symptom ControlSymptom Control Prolong life by weeksProlong life by weeks Prolong life by monthsProlong life by months Known to specialist palliative care Known to specialist palliative care
serviceservice Views of other HCP’sViews of other HCP’s Is patient well informed of the aboveIs patient well informed of the above Conclusion : Conclusion :
Check List Prior To Each Dose Check List Prior To Each Dose ChemotherapyChemotherapy
Performance status ? Barthel ScorePerformance status ? Barthel Score Evidence of disease status, clinical Evidence of disease status, clinical
and objective (radiological, tumour and objective (radiological, tumour markers etc)markers etc)
Side Effects of Treatment (toxicity)Side Effects of Treatment (toxicity) Patients Views and understandingPatients Views and understanding Support MechanismsSupport Mechanisms