Earlier End-of-Life Talk Associated with Less Aggressive Late Care

shared decision-makingEarly discussions about desired end-of-life care, among patients with incurable cancer, were associated with less aggressive treatment in the last month of life, according to a study published this week in the Journal of Clinical Oncology (Nov. 13 online ahead of print).

The American Society of Clinical Oncology (ASCO) highlighted this study for providing “the first-of-its-kind scientific evidence that timing of end-of-life discussions affects decisions” and actual treatment given at the end of a patient’s life.

The study found that nearly 40% of end-of-life discussions with cancer patients happened in the last 30 days of life. Among patients who had such discussions earlier, they were much more likely to receive hospice care and less likely to be treated aggressively at the end of life.

The prospective study, done by Dana-Farber Cancer Center, was drawn from a cohort group of 10,000 patients diagnosed with lung or colon cancer between 2003 and 2005 in multiple centers. The researchers focused on 1,231 patients who had highly advanced (stage IV) lung or colorectal cancer at first diagnosis and who died sometime within the 15-month study period. Specific information about end-of-life discussions was drawn from both interviews and medical-record analysis.

During the study and before their death, 88% of patients (or their surrogates) had end-of-life discussions with a physician. Nearly 40% of those discussions took place in the last 30 days of life.

Patients were less likely to report documented discussions if they were unmarried, black or Hispanic, or not enrolled in a health maintenance organization.

Nearly half of the study participants received at least one type of “aggressive end-of-life care” defined in several ways: 16% received chemotherapy in the last 14 days of life; 9% were admitted to an ICU; and 40% were hospitalized in the last month of life.

Patients who had earlier discussions (before the last 30 days of life) were more likely to use hospice care (68-77% vs. 49%) and less likely to receive aggressive types of treatment.

Jennifer Mack, MD, MPH, Dana-Farber Cancer Center

The authors noted that this type of cohort study only shows association—not cause—between earlier discussions and less aggressive end-of-life treatment. Lead author Dr. Jennifer Mack noted that aggressive treatment at the end of life is not necessarily wrong, but that “physicians seem to wait until the patient begins deteriorating medically.”

“Others have suggested that end-of-life decision-making requires time; most patients need to process the idea that life is nearing its end before they can make decisions,” the authors wrote. “When discussions begin in the last 30 days of life, the end-of-life period is typically already under way. Importantly, clinicians may not know when the last month of life is about to begin.”

 Instead, physicians should consider moving conversations closer to the time when incurable cancer is first diagnosed, they concluded.

Patient take-away

Discussions about your personal goals for medical care and quality of life are much easier to have with family and/or your doctor in times of relative calm. There’s no need to wait for your doctor to bring up the subject; it’s your life. It can be comforting for family to remind them that people who are receive palliative or hospice care tend to actually live longer.

Sources: “Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study,” Journal of Clinical Oncology published online on November 13, 2012; and Medscape Oncology, Nov. 13 2013 .

 

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