title: Dying well: How equal is end of life care among gynecologic oncology patients?
abstract: OBJECTIVE
  To identify disparities in utilization of end of life (EoL) resources by gynecologic oncology (GO) patients.
  
  
  METHODS
  This retrospective analysis of the medical records of GO patients treated 1/2007-12/2011 and deceased 1/2012-8/2014 evaluated patient demographics, disease characteristics, and utilization of EoL resources. Chi-square, Fisher's exact test, Mann Whitney and Kruskal-Wallis tests were used for statistical analysis.
  
  
  RESULTS
  Of 189 patients analyzed, 113 (60%) were white, 38 (20%) Hispanic, 31 (16%) black, and seven (4%) Asian. Ninety-five (48%) had ovarian cancer, 51 (26%) uterine, 47 (23%) cervical, seven (3%) vulvar/vaginal. In the last 30days of life (DoL), 18 (10%) had multiple hospital admissions, 10 (5%) admitted to the Intensive Care Unit (ICU), 30 (16%) multiple Emergency Room (ER) visits, 45 (24%) received aggressive medical care and eight (4%) received chemotherapy in the final 14 DoL. Furthermore, 54 (29%) had no Supportive Care referral and 29 (15%) no hospice referral. Only 46 (24%) had a Medical Power of Attorney (PoA) or Living Will (LW) on file. Non-white race was associated with increased odds of dying without hospice (OR 3.07; 95%CI [1.27, 2.46], p=0.013). However, non-white patients who enrolled in hospice did so earlier than white patients (42 v. 27days before death, p=0.054). Non-white patients were also significantly less likely to have PoA/LW documentation (24% v. 76%, p=0.009) even if enrolled in hospice (12% v. 31%, p=0.007).
  
  
  CONCLUSIONS
  Significant racial disparities in hospice enrollment and PoA/LW documentation were seen in GO patients. This warrants further study to identify barriers to use of EoL resources.
authors.affiliation: The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States. Electronic address: Jstaylor1@mdanderson.org.
authors.forename: Jolyn S
authors.initials: JS
authors.lastname: Taylor
authors.affiliation: The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Alaina J
authors.initials: AJ
authors.lastname: Brown
authors.affiliation: The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Lauren S
authors.initials: LS
authors.lastname: Prescott
authors.affiliation: The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Charlotte C
authors.initials: CC
authors.lastname: Sun
authors.affiliation: The Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Lois M
authors.initials: LM
authors.lastname: Ramondetta
authors.affiliation: The Department of Medical Education, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Diane C
authors.initials: DC
authors.lastname: Bodurka
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000208:ethnology / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005833:Genital Neoplasms, Female / Q000208:ethnology / Q000628:therapy*; D054625:Healthcare Disparities / Q000208:ethnology / Q000706:statistics & numerical data*; D006738:Hospices / Q000706:statistics & numerical data; D006801:Humans; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods* / Q000592:standards*; D055815:Young Adult
keywords: Advance directives; End of life care; Hospice