Keywords
best supportive care - in-hospital deaths - mortality audit - neutropenic sepsis -
non-neutropenic sepsis - progressive disease
Introduction
Cancer is the second leading cause of death worldwide. Low- and middle-income countries
account for approximately 70% of cancer-related deaths.[1] The advent of newer drugs and therapies in oncological practice has led to increased
cure rates and overall survival in cancer patients. However, advanced-stage cancer
is seldom curable, and cancer-related death becomes an inevitable phenomenon. There
can be various causes of death in a cancer patient. Death can be (1) disease-related,
like progressive disease and primary organ failure, (2) those related to treatment
or intervention like neutropenia and sepsis, and (3) due to causes unrelated to cancer,
fro example, comorbidities. A health care provider should be astute enough to anticipate
the causes and possibility of death in cancer patients. Mortality audit is an exercise
to critically appraise the causes and circumstances leading to the death of the patients
and the remedial steps which might have prevented the unexpected death. Aim of the
mortality audit in an oncological setting should be to identify the preventable causes
of death, to avoid treatment and interventions which are unlikely to provide a palliation
or survival benefit in last few days of life, and to identify the modifiable factors
and interventions likely to improve the quality of care and outcomes. The data regarding
death of cancer patients outside the jurisdiction of clinical trials is scarce, especially
in the developing countries including India.
A judicious mortality audit should serve as a benchmark for future improvement; this
led to the inception of this study.
A newly established medical oncology and hemato- oncology center in a resource-constrained
geographical area has the challenge to provide optimum cancer care, and it has to
improve progressively.
All India Institute of Medical Sciences (AIIMS) at Rishikesh, Uttarakhand, India,
is a tertiary care center under the Ministry of Health and Family Welfare. We started
hemato-oncology services in 2016 and medical oncology services in 2018. We have a
teaching unit, including a 26-bed inpatient department and a 20-bed day care, serving
nearby, rural and remote population in a radius of almost 300 km. We present our first
audit of in-hospital deaths in cancer patients.
Material and Methods
We performed an audit of all in-hospital deaths in the department of medical oncology
and hemato-oncology between January and December 2019. All in-hospital deaths that
occurred during this period were identified from the computerized patient records,
and case files were retrieved from the medical records department. An audit design
was prepared for compiling the data. Parameters for assessment included were age,
gender, residence, Eastern Cooperative Oncology Group-Performance Status (PS), type
of cancer, stage of cancer, comorbidities, the intent of treatment or intervention
(palliative, curative, or best supportive), type of last treatment or intervention
received (chemotherapy or procedure), any improvement in PS due to last intervention,
period of hospital stay prior to death, and the cause of death. Permission from the
medical superintendent was obtained for carrying out the audit. The audit was approved
by the institutional ethics committee.
The audit was reviewed by-two independent observers. The final report was submitted
to the Dean, research advisory committee of the institute. A fidelity statement was
generated to perform audits at regular intervals to identify areas for improvement.
Results
We registered 45 in-hospital deaths in the year 2019. These included 28 patients of
solid organ malignancies and 17 of hematological malignancies. The mean duration of
hospital stay before death was 9 (range 1–33) days. The median age of the patients
at the time of death was 47 (range 2–82) years. Seventeen cases were outside Uttarakhand
state. Seven patients had one or more comorbid illnesses ([Table 1]).
Table 1
Patient’s characteristics
|
Parameters
|
Numbers
|
|
Median age
|
47 (2–82) y
|
|
Males
|
31
|
|
Females
|
14
|
|
Residence
|
|
|
Uttarakhand
|
28
|
|
Outside Uttarakhand
|
17
|
|
Patients with one or more comorbidities (n = 7)
|
|
|
Type 2 diabetes mellitus
|
1
|
|
Chronic kidney disease
|
1
|
|
Chronic liver disease (hepatitis B related)
|
1
|
|
Chronic liver disease (hepatitis C related)
|
1
|
|
Dilated cardiomyopathy
|
1
|
|
Hepatitis B infection
|
1
|
|
Coronary artery disease
|
1
|
|
Stage (solid organ cancers)
|
|
|
3
|
5
|
|
4
|
23
|
|
Performance status (ECOG) at the time of last intervention received
|
|
|
0
|
0
|
|
1
|
3
|
|
2
|
11
|
|
3
|
16
|
|
4
|
12
|
|
Primary diagnosis
|
|
|
Acute leukemia
|
12
|
|
Lung cancer
|
5
|
|
Genitourinary cancer
|
5
|
|
Head and neck cancer
|
4
|
|
Pancreaticobiliary cancer
|
3
|
|
Ovarian cancer
|
3
|
|
Cancer of unknown primary
|
3
|
|
Gastrointestinal cancer
|
2
|
|
Neuroendocrine cancer
|
1
|
|
Breast cancer
|
1
|
|
Plasma cell leukemia
|
1
|
|
Multiple myeloma
|
1
|
|
Chronic myeloid leukemia
|
1
|
|
Myelodysplastic syndrome
|
1
|
|
Sarcoma
|
1
|
|
Non-Hodgkin lymphoma
|
1
|
|
Intent of the treatment (solid organ cancer, n = 28)
|
|
|
Curative
|
4
|
|
Palliative including chemotherapy
|
8
|
|
Best supportive care
|
15
|
|
Intent of the treatment (hematological cancer, n = 17)
|
|
|
Curative
|
9
|
|
Palliative including chemotherapy
|
1
|
|
Best supportive care
|
7
|
|
Causes of death
|
|
|
Progressive disease
|
21
|
|
Neutropenic sepsis
|
9
|
|
Non-neutropenic sepsis
|
4
|
|
Pulmonary embolism and respiratory failure
|
3
|
|
Perforation peritonitis
|
2
|
|
Sudden cardiac death
|
2
|
|
Ventricular tachycardia
|
1
|
|
Myocardial infarction
|
1
|
|
Hypovolemic shock
|
1
|
|
Coagulopathy-associated bleed
|
1
|
|
Mean duration of hospital stay in the last admission (d)
|
9 (range 1–33)
|
Abbreviations: ECOG, Eastern Cooperative Oncology Network, PS, Performance Status.
Note: Three patients of pediatric age group had a Lansky PS of 10, 10, and 70 each.
Among solid organ malignancy patients, 23 (82.14%) patients had metastatic disease
and the intent of the treatment was palliation, including palliative chemotherapy
in 15 patients and limited to best supportive care (BSC) in 8 patients. Five patients
(17.8%) received chemotherapy with curative intent. Eight patients with palliative
intent chemotherapy had prior received one or more lines of chemotherapy. Twenty-four
deaths were unrelated to chemotherapy/intervention received during the last 4 weeks
of life in patients with solid organ malignancies. The various causes included thromboembolism
and respiratory failure, non-neutropenic sepsis, progressive disease, multiorgan failure,
coagulopathy-associated bleeding, myocardial infarction, ventricular tachycardia leading
to cardiogenic shock, and perforation peritonitis.
Causes of death related to chemotherapy/intervention included neutropenic sepsis in
three patients, and hypovolemic shock after peritoneocentesis in one patient of refractory
mucinous ovarian adenocarcinoma. Five deaths occurred in patients receiving treatment
with curative intent. Causes included pulmonary embolism, neutropenic sepsis, non-neutropenic
sepsis and progressive disease, sudden cardiac death, and non-neutropenic sepsis with
acute respiratory distress syndrome.
Among hematological malignancies, 9 patients were treated with curative intent, 1
with palliative, and 7 received BSC. Nine deaths were unrelated to chemotherapy, and
the causes included progressive disease with encephalopathy, stroke, and multiorgan
failure. Eight deaths were attributed to chemotherapy-related neutropenic sepsis.
Treatment/intervention received in the last 4 weeks of life included chemotherapy
in 30 patients, radiotherapy in 1 patient, and therapeutic procedure in 6 patients.
Procedures included peritoneal catheter insertion and peritoneocentesis in 3 patients,
percutaneous transluminal biliary drainage, pericardiocentesis, and thoracocentesis
each in 1 patient. Three patients received more than one treatment/intervention. BSC,
including palliative procedure, was provided to 11 patients.
Chemotherapy doses were found to be appropriate and as per protocol. Judicious use
of growth factors and blood component therapy was done wherever needed. Institutional
policy for the use of antibiotics was followed religiously.
In the cohort of death of patients receiving palliative chemotherapy (n = 15) in solid organ cancers, it was observed that chemotherapy could have been avoided
in 8 patients as they had poor prognostic factors namely PS 3 or 4, multiple comorbidities,
receiving second or subsequent lines of chemotherapy, or a combination of more than
one factor. Although deaths were due to progressive disease in all of these patients,
adding chemotherapy in these patients did not lead to improvement in PS or symptoms.
Referrals to the intensive care unit in three patients receiving BSC were also considered
as nonessential.
Discussion
This is a single-institution study of in-hospital deaths in a medical oncology, hemato-oncology
set up. A large proportion of deaths (37.7%) were observed in patients outside Uttarakhand
state as many patients travel to our institute from adjoining states of Uttar Pradesh,
Haryana, and Himachal Pradesh for oncology services. Our audit report suggests that
optimum care was delivered to prevent mortality and morbidity in patients receiving
definite anticancer therapy in the form of appropriate antibiotics, anticoagulation,
blood components transfusion, growth factors support, and intensive care support if
required. No attempts were made to unnecessarily prolong the survival in patients
receiving exclusive BSC.
Eight patients who were receiving second and subsequent lines of therapy demonstrated
no improvement in PS or symptom improvement after the last cycle of systemic anticancer
therapy. Discontinuation of systemic anticancer therapy can be considered for these
patients after considering other clinical and demographic parameters like life expectancy,
comorbidities, patient’s goal of care, financial toxicities, and travel from a remote
area as chemotherapy-related complications can be fatal for them. Deciding the appropriate
role of chemotherapy near the end of life can be difficult. Various studies have indicated
that chemotherapy was used frequently in the last 3 months of life. The use of chemotherapy
toward the end of life should only be done when some realistic benefit is expected.
Emphasis should be on BSC for those patients who have multiple comorbidities, poor
PS, and progressed on first line chemotherapy.[2]
[3]
Most of the younger patient’s deaths were seen in the hematological malignancies group.
These were usually treatment-related and occurred within a year of starting systemic
therapy. Most of these deaths were due to febrile neutropenia and sepsis. Similar
results have been seen in other studies. Various factors like the type of malignancy,
comorbidities, and infectious complications, are associated with increased mortality
in patients who develop febrile neutropenia and sepsis. These factors serve as useful
parameters for recognizing patients at heightened risk of grave morbidities and mortality,
prompting aggressive approach.[4]
[5]
It has been seen that there is a poor acceptance for BSC among attendants of a terminally
ill cancer patient. This may be due to various reasons like lack of social support
at home, poor communication from the treating team, poor understanding of the disease
and prognosis on the part of attendants, nonacceptance of a terminal illness due to
emotional impact, and not considering BSC as a form of treatment. Every effort should
be made from the treating team to educate the patient’s attendants regarding the terminal
and nonresponding nature of the cancer. They should be made aware that quality of
life should be a priority instead of chasing an invisible foe and BSC is a comprehensive
accompaniment taking care of optimal physical and psychosocial needs of the patient.
The decision to shift a patient on BSC either at home or in a specialized hospice
center should be a collective one among the treating team and the usual attendants
of the patient.[6]
Conclusion
Mortality audits give us an opportunity to review the practices and services being
delivered. They create a window for subsequent improvement as each audit serves as
a benchmark for prospective audit. BSC should be strongly considered instead of systemic
anticancer therapy in patients with poor PS, terminal illness, progression on subsequent
lines of chemotherapy, multiple comorbidities, or a combination of one or more of
these factors. This study invigorates the idea of performing death audits from other
cancer institutes of India and rest of the world.
