A large population- and health systems-based prospective study reports earlier discussions about end of life (EOL) care preferences are strongly associated with less aggressive care in the last days of life and increased use of hospice care for patients with advanced cancer.
The study, published November 13 in the Journal of Clinical Oncology, provides the first-of-its-kind scientific evidence that timing of EOL care discussions affects decisions about EOL care.
The findings suggest that initiating EOL care discussions before the last month of life provides the patients opportunity to make decisions regarding their EOL care preferences in a way that late discussions don't seem to do. Patients need time to process the information with their family and make good plans based on that information.
National guidelines recommend that oncologists initiate discussions about EOL care soon after a diagnosis of advanced cancer in order to ensure care aligns with patient goals and wishes. Current guidelines state that conversations should happen "during periods of relative medical stability rather than acute deterioration, and with physicians that know the patient well." In addition, ASCO's own recommendations for patients with advanced cancer include prioritizing discussions related to advanced cancer care preference upon diagnosis. This year ASCO also offered guidance on when oncologists should prioritize palliative and supportive care for patients with advanced cancer who have certain disease characteristics.
"Research has shown that choosing less aggressive care at the end of life offers important benefits for both patients and their caregivers. Patients have 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," said lead author Jennifer W. Mack, MD, MPH, a pediatric hematologist/oncologist at Dana-Farber/Children' Hospital Cancer Center. "This is also important because studies have shown that aggressive care is associated with a higher risk of depression among bereaved caregivers of cancer patients."
In the study, investigators identified discussions about hospice and resuscitation from with 1,231 patients (or surrogates of patients who were deceased or too ill to participate) with end-stage lung or colorectal cancer and via review of their medical records. They found that, on average, EOL discussions were initiated 33 days before death and 39 percent of those discussions occurred within the last 30 days.
Nearly half of all the study participants received at least one form of aggressive care, including chemotherapy in the last 14 days of life, intensive care unit (ICU) care in the last 30 days of life, and acute, hospital-based care in the last 30 days of life. However, compared with cases where EOL discussions took place within the last 30 days of life, cases with earlier EOL discussions were associated with less frequent use of aggressive care (34-45 percent vs. 65 percent) and increased use of hospice care (68-77 percent vs. 49 percent).
"Most patients who recognize that their cancer is terminal want to receive less aggressive care at the end of life," said Dr. Mack. However, aggressive care is still common in this setting, in part because discussions about the end of life are often postponed because they are difficult for both physicians and patients. This study also found that 17 percent of patients or surrogates did not recall EOL care discussions even though they were documented in the medical records, suggesting they may not have fully comprehended the content of the discussion.
The authors emphasize that more research is needed to explore how content of EOL care discussions affects patients' comprehension of the information and subsequent decisions made. In addition, the study underscores a need for a national emphasis from ASCO and many other professional and patient groups on advanced cancer care planning in physician education and training programs.
ASCO Perspective: Sandra M. Swain, MD, FACP, ASCO President
"Conversations about treatment options for advanced cancer are extremely difficult for patients, their families and their oncologist. But this study underscores a growing body of evidence that the earlier these conversations take place, the better because they have a real impact on a patient's quality of life in their final days. We need more education for physicians on topics like this and more training on communication skills for discussing prognosis."
- Jennifer W. Mack, Angel Cronin, Nancy L. Keating, Nathan Taback, Haiden A. Huskamp, Jennifer L. Malin, Craig C. Earle, and Jane C. Weeks. Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study. Journal of Clinical Oncology, 2012; DOI: 10.1200/JCO.2012.43.6055
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