End of Life Discussions with Doctors Help Patients and Caregivers

When advanced cancer patients talk with their doctors about preparing for the end of their lives, they have a better quality of life as death approaches.  They aren’t more likely to be depressed, and they receive less aggressive care in the last week of life.

Because it is frightening and uncomfortable, many patients don’t bring up the subject with their doctors.  Doctors avoid end-of-life discussions because they, too, find them uncomfortable and because they fear depressing patients or causing emotional problems.

Boston researchers interviewed 332 terminally ill cancer patients and their caregivers, following them until the patient’s death.  They also studied caregiver emotional health up to six months after their family member died.  Only about a third (37 percent) of patients had talked about the end of their lives with their doctor at the time of the first research interview.

Patients who talked about dying with their doctors didn’t have more major depression, nor did they worry more.  They did have more aggressive care in the last week of life.  Compared to patients with no end-of-life discussion:

• 1.6 percent versus 11 percent were placed on a ventilator
• less than 1 percent versus 6.7 percent were resuscitated
• 4.1 percent were admitted to the ICU compared to 12.4 percent

Patients who discussed end of life plans with their doctors had earlier enrollment in hospice which led to a better quality of life.  Aggressive treatment reduced quality of life.

Caregivers also fared better.  When there had been no discussion of end-of-life care, family caregivers were more than three times as likely to have major depression in the months after the patient died.  They had more regrets, more health concerns, and said that they were unprepared for the patient’s death.

When patients had a good quality of life before death, caregivers also reported better quality of life — before and after the death.

Alexi A. Wright, M.D. and her colleagues wrote,

Our results suggest that end-of-life discussions may have cascading benefits for patients and their caregivers. Despite physicians’ concerns that patients may experience psychological harm due to end-of-life discussions, we found no evidence that they were significantly associated with increased emotional distress or psychiatric disorders. Instead, the worst outcomes were seen in patients who did not report having these conversations.

 

Given the adverse outcomes associated with not having end-of-life discussions, there appears to be a need to increase the frequency of these conversations. By acknowledging that death is near, patients, caregivers, and physicians can focus on clarifying patients’ priorities and improving pain and symptom management.

SOURCE: Wright et al., Journal of the American Medical Association, Volume 300, Number 14, October 8, 2008.