title: Too much, too late: Aggressive measures and the timing of end of life care discussions in women with gynecologic malignancies.
abstract: OBJECTIVE
  This study describes the patterns of end of life (EOL) discussions and their impact on the use of aggressive measures in women with terminal gynecologic malignancies at a single institution.
  
  
  METHODS
  An IRB-approved retrospective chart review identified 136 patients who died of gynecologic cancer between 2010 and 2012 with at least one interaction with their oncologists in the last 6 months of life. Aggressive measures were defined as chemotherapy within the last 14 days of life, emergency department (ED) visits, hospital and intensive care unit (ICU) admissions within the last 30 days of life, and inpatient deaths. The frequency and timing of EOL conversations were recorded. Utilization of hospice care was also described.
  
  
  RESULTS
  In the last 30 days of life, 54 (40%) patients were evaluated in the ED, 67 (49%) were admitted into hospital, and 16 (12%) were admitted to the ICU. Thirteen patients (10%) had chemotherapy in the last 14 days of life. Ninety-seven (71%) patients had a documented EOL conversation, eighteen (19%) as outpatients, and 79 (81%) as inpatients. Thirty (22%) patients died in the hospital. At the time of death, 55 (40%) patients were enrolled in outpatient hospice care. The mean amount of time in hospice was 28 days.
  
  
  CONCLUSIONS
  End of life care discussions rarely occurred in the outpatient setting or >30 days before death. Inpatient encounters led to discussions about hospice and code status. Evaluation in the ED frequently resulted in escalation of care. Earlier EOL care discussions resulted in less aggressive measures.
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA. Electronic address: zakhourm@cshs.org.
authors.forename: Mae
authors.initials: M
authors.lastname: Zakhour
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
authors.forename: Lia
authors.initials: L
authors.lastname: LaBrant
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
authors.forename: B J
authors.initials: BJ
authors.lastname: Rimel
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
authors.forename: Christine S
authors.initials: CS
authors.lastname: Walsh
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Li
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
authors.forename: Beth Y
authors.initials: BY
authors.lastname: Karlan
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
authors.forename: Ilana
authors.initials: I
authors.lastname: Cass
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital; D005260:Female; D005833:Genital Neoplasms, Female / Q000188:drug therapy / Q000628:therapy*; D017051:Hospice Care / Q000706:statistics & numerical data; D006801:Humans; D008875:Middle Aged; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods* / Q000592:standards; D013997:Time Factors