Chemotherapy Audit  Audit of patients who died within three months of their last dose of chemotherapy at Airedale General Hospital  The records of 50 patients who had died within three months of their last dose of chemotherapy were identified and then examined according to a proforma.  The aim was to have an estimate of the incidence of this occurrence, to audit record keeping, decision making, and to try and assess if chemotherapy had been appropriately given.

Chemotherapy Audit  Reviewing the literature there is very little information on what the expected percentage of cancer patients who die within three months of chemotherapy is.  A study from Massachussetts in 1996, looking at a population of 8,000 cancer patients found that  41% of patients received chemotherapy in the last year of life  33% in the final 6 Months  25% in the final 3 months  9% in the last month  They tried to assess if chemotherapy had been given appropriately dividing patients in to groups of tumours thought to be sensitive to chemothotherapy and those not. They found no difference in rates of treatment given

Chemotherapy Audit  No comparable data could be found for the UK or more recent.  The population served by AGH is approximately 205,000  Approx Number of Deaths from Cancer per year  Craven : 145  Airedale : 341  Pendle : 47  Total : 533

Chemotherapy Audit  48 sets of notes found and audited  Covering a period from 4/4/02 to 31/01/03 approximately 10 months All patients were receiving palliative chemotherapy not adjuvant  Equivalent to 1.2 X 48 deaths per year = 58 deaths per year within 3 months of chemotherapy.  11% of patients dying from cancer had chemotherapy within the last 3 months within AGH catchment area.( This does not include private patients or those receiving chemotherapy else where)

Audit  Sex Female : 26(54%) Female : 26(54%) Male : 22 (45%) Male : 22 (45%)  Age Range (8%) (8%) (23%) (23%) (27%) (27%) (36%) (36%) 81 – 903 (6%) 81 – 903 (6%)

Cancers treated over the last 5 years 2000 to Oct 31st 2004  Sex Ratio F 688(61%) M 434(39%) Age Ranges  (.6%)  (4%)  (10%)  (27%)  (29%)  (29%)  (4%)

All Trust Patients Oncology Deaths 0304 monthyeardischTotal Apr-032 May-033 Jun-031 Jul-038 Aug-035 Sep-033 Oct-035 Nov-032 Dec-032 Jan-045 Feb-046 Mar-048 Grand Total50 Oncology Inpatient Deaths 03/04 (All Deaths : 830) Oncology Deaths Average Length of Stay(DAYS) 0304 monthyeardischTotal Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Grand Total10.8

Diagnosis of Patients who died within 3 months of their chemotherapy Cancer DiagnosisNumber of Patients (days from last chemotherapy to death) Cancer DiagnosisNumber of Patients (days from last chemotherapy to death)  Non small cell lung14 (4, 10, 16, 21, 23, 26, 26, 34, 38, 46, 49,54, 73,84) 49,54, 73,84)  Colo-Rectal9 (9, 18, 21, 21, 23, 36, 41, 55, 58)  Ca Pancreas7 (1, 8, 9, 11, 15, 20, 59)  Small Cell Ca Lung5 (2, 4, 5, 37, 5)  Breast Cancer5 (9, 13, 27, 42, 5)  Ovarian4 (13, 27, 40, 4)  Bladder1 (12)

Diagnosis*2000*2001*2002*2003*2004Total Breast Colon NSCCL SCLC Ovary Rectal Pancreas Bladder Gastric Oesophageal Adeno Prostate Mesothelioma Unknown Endometrial Malignant Melanoma Cholangio Peritoneal Renal Others12 Total1122 Chemotherapy Given by Diagnosis 2000 to Oct 31 st 2004

Diagnosis of Patients who died within 1 month of their chemotherapy Cancer DiagnosisNumber of Patients (days Cancer DiagnosisNumber of Patients (days from last chemotherapy to death) from last chemotherapy to death)  Non small cell lung7 (4, 10, 16, 21, 23,26, 26)  Ca Pancreas6 (1, 8, 9, 11, 15, 20)  Colo-Rectal5 (9, 18, 21, 21, 23)  Small Cell Ca Lung3 (2, 4, 5)  Breast Cancer3 (9, 13, 27)  Ovarian2 (13, 27)  Bladder1 (12)

Diagnosis of Patients who died within 1 week of their last dose of chemotherapy  Cancer Diagnosis Number of Patients (days from last chemotherapy to death) (days from last chemotherapy to death)  Small Cell Ca Lung 3 (2, 4, 5)  Non Small Cell Lung 1 (4)  Pancreas1 (1)

Diagnosis of Patients who died within 1 to 2 weeks of their last dose of chemotherapy  Cancer DiagnosisNumber of Patients (days from last chemotherapy to death) chemotherapy to death)  Pancreas 3 (8, 9, 11)  Breast 2 (9,13)  Colon 1 (9 )  Bladder 1 (12)  Non Small Cell Ca Lung 1 (10)  Ovary 1 (13)

Chemotherapy Regimen and Death within three months Regime Number of Deaths within 3 months Regime Number of Deaths within 3 months  Vinorelbine6  5 FU and Folinic Acid5  (Mitomycin,Vinblastin,5  Cisplatin)  ECF5  Carboplatin4  Gemcitabine3  (Doxorubicin,Vincristine3  +/-Cyclophosphamide)  (Vinorelbine,Cisplatin)2  Liposomal Doxirubicin2  Exatecan2  Irinotecan2  Others9

Number of patients Neutropenic Near to or on day of death  5 patients were neutropenic at death  Patient No DiagnosisLast Chemo Days from death death  17 PancreasExatecan 8  44 NSCCLVinorelbine10  42 OvaryLip Doxorubicin 13  5 Colorectal5FU + Folinic acid 18  26 BreastFEC 62 6 other patients were neutropenic within 2 weeks of death but their counts had risen prior to death 6 other patients were neutropenic within 2 weeks of death but their counts had risen prior to death

Conclusions 1  All patients were having palliative chemotherapy  NSCLC and Pancreatic cancers high risk  Recording of information not always sufficient  No clear documentation of decision making  This does not mean appropriate decisions were not made but they were not recorded

Conclusions 2  Difficult to assess appropriateness of chemotherapy as information not there  Profroma needed to capture information  CPR decisions need to be made more routinely  Deaths within 3 weeks should be routinely audited  Need to compare results with other units  Need for separate audit of outcomes from neutropenic sepsis  Place of death more likely to be in hospital

Conclusions 3  Need for MDT discussion for patients with poor performance status  ? Review with each cycle  Consent clinic  Survey of patients/carer’s views  Role of Palliative care team in these decisions?

Role of Palliative Care  Palliative Chemotherapy becoming more common. e.g. Lung (NSCCL), Pancreas, 2 nd 3 rd 4 th 5 th line Rx for breast, ovary, colorectal.  Some evidence it can improve quality of life  Balance between benefits and burdens becoming more difficult to assess.  Needs ongoing research and collaboration33

Possible Proforma 1 Palliative chemotherapy assessment for ongoing treatment Palliative chemotherapy assessment for ongoing treatment  Should treatment continue, stop or be changed  Performance status (last 4)  QOL question (last 4)  Tumour markers last 4 results (or graph)  Recent radiology Summary of findings  Disease responding Stable Stable Progressive Progressive

Possible Proforma 2  Side effects from treatment  Recent episodes of Neutopenia/thrombocytopenia/anaemia  Dose reduction considered  Patients view on continued treatment Keen Keen Ambivelent Ambivelent Not keen Not keen  CPR status

Possible Proforma 3  Overall aim of treatment Symptom Control Symptom Control Prolong life by weeks Prolong life by weeks Prolong life by months Prolong life by months  Known to specialist palliative care service  Views of other HCP’s  Is patient well informed of the above  Conclusion :

Check List Prior To Each Dose Chemotherapy  Performance status ? Barthel Score  Evidence of disease status, clinical and objective (radiological, tumour markers etc)  Side Effects of Treatment (toxicity)  Patients Views and understanding  Support Mechanisms