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End-of-life discussions lead to less aggressive care, more use of hospice

By Carmen Phillips
NCI Cancer Bulletin 

Patients with advanced cancer who discussed end-of-life care with their doctors earlier in the course of their illness had care that was less aggressive in their last month of life and were more likely to use hospice services, according to a new study.

Earlier discussions may help to ensure that care at the end of life is more consistent with patients’ preferences, the study authors explained.

Yet, on average, these discussions took place about 1 month before a patient died, they found.

The study was published online November 13 in the Journal of Clinical Oncology (JCO).

Although some patients may wish to have aggressive care at the end of life, “most patients who recognize that their cancer is terminal want to receive less-aggressive care,” the study’s lead investigator, Dr. Jennifer Mack of the Dana-Farber Cancer Institute, said in a news release.

The American Society of Clinical Oncology and other groups recommend that discussions about palliative and end-of-life care begin shortly after a patient has been diagnosed with advanced cancer.

Several studies have found that such discussions between physicians and patients with advanced cancer are often delayed until late in a patient’s life, if they take place at all.

For example, an earlier study by Dr. Mack and her colleagues found that oncologists had end-of-life care discussions with only about one-quarter of their patients, and, when the end-of-life care discussions took place, they often happened in the hospital during episodes of acute care.

In the new study, researchers analyzed patient (or patient surrogate) interviews and the medical records of more than 1,200 patients with end-stage lung or colorectal cancer regarding discussions about end-of-life care, including resuscitation and hospice care.

All patients in the study lived for at least 1 month after diagnosis and were participants in the NCI-funded Cancer Care Outcomes Research and Surveillance Consortium.

Almost half of the patients had at least one form of aggressive care in the last month of their lives: 16 percent of patients underwent chemotherapy within the last 2 weeks of life, 40 percent received acute care in the hospital within the last 30 days of life, and 6 percent were treated in the intensive care unit in the last 30 days of life.

Patients who had end-of-life care discussions earlier, however, were much less likely to receive aggressive care and more likely to receive hospice care.

Most patients who recognize that their cancer is terminal want to receive less-aggressive care. —Dr. Jennifer Mack

The results “really highlight that much more work needs to be done to address this long-standing problem,” said Dr. Ann O’Mara, a program director in NCI’s Division of Cancer Prevention who leads the institute’s palliative care research program.

In a March 2012 interview with the NCI Cancer Bulletin, Dr. Thomas Smith, director of palliative care for the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, noted that discussions about palliative care should begin shortly after diagnosis, even with patients who do not have a terminal cancer. However, these discussions are particularly important for patients with incurable cancers, he said.

“Most [oncologists] choose not to have discussions about things like hospice, do-not-resuscitate [orders], and advance medical directives until there are no more chemotherapy options left,” he said. “That allows us to avoid a hard conversation, but it doesn’t serve as well to prepare the patients and families for what’s coming.”

Less-aggressive care near the end of life can clearly benefit patients and their families, Dr. Mack commented.

Aggressive end-of-life care has been linked to a higher risk of depression among caregivers after the patient has died, she explained. And for patients, less-aggressive care can mean “a better quality of life in their final days, because there is a greater focus on symptom management and they are more often able to receive care in their homes,” she said.

Now that several studies (for example, here and here) have documented that earlier palliative care can improve patients’ quality of life and, in some cases, may have improved survival, Dr. O’Mara believes the time is ripe for “an intervention trial that examines the timing and frequency of doctor-patient conversations and the impact they have on patients and families,” particularly with regard to care decisions and their psychosocial impact on family members and caregivers.

This research was supported by grants from the National Institutes of Health (U01 CA093344, U01 CA093332, U01 CA093324, U01 CA093348, U01 CA093329, U01 CA093339, and U01 CA093326).

Further reading: “Last Days of Life” and “Palliative Care Improves Survival, Quality of Life in Advanced Lung Cancer

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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