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, 2012 issue of the Journal of Clinical Oncology, provides the first-of-its –kind scientific evidence that timing of End of Life care discussions affects decisions about EOL care.
The findings suggest that initiating End of Life (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 End of Life 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, recommendations for patients with advanced cancer from ASCO, the American Society of Clinical Oncology include prioritizing discussions related to advanced cancer care preference upon diagnosis. ASCO also offers guidance on when oncologists should prioritize palliative and supportive care for patients with advanced cancer who have certain disease characteristics.
"While improving survival is the oncologist’s primary goal, helping individuals live their final days in comfort and dignity is one of the most important responsibilities of our profession,” said George W. Sledge, Jr., MD commenting on the need of End of Life strategies. "Patients have a right to make informed choices about their care, including EOL care. Oncologists must lead the way in discussing the full range of curative, palliative therapies and EOL care options to ensure that patients’ choices are honored.”
Benefits of less aggressive care
“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% 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% vs. 65%) and increased use of hospice care (68-77% vs. 49%).
Patients’ comprehension of the information
“Most patients who recognize that their cancer is terminal want to receive less aggressive care at the end of life,” said 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% 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.
A growing need
Commenting on the study, Sandra M. Swain, MD, FACP, ASCO President said “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.”
Unrelated studies have shown that early convesrations about palliative therapies and EOL care not only improve patient quality of life, but can even extend life. Unfortunately, for many patients with advanced cancer, conversations about palliative and hospice options do not occur until the patients’ final weeks or days of life, if they happen at all. This not only hurts patients, but their caregivers as well.
 Jennifer W. Mack, M.D. MPH is the recipient of a 2005 Conquer Cancer Foundation of ASCO Young Investigator Award (YIA) and 2007 Career Development Award (CDA)
For more information:
Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL, Earle CC, Weeks JC. Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study. J Clin Oncol. 2012 Nov 13. [Epub ahead of print]
Mack JW, Cronin A, Toback N, Huskamp HA, Keating NL, Malin JL, Earle CC, Weeks JC.
End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med. 2012 Feb 7;156(3):204-10.
Peppercorn JM, Smith TJ, Helft PR, DeBono DJ, Berry SR, Wollins DS, Hayes DM, Von Roenn JH, Schnipper LE. American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer J Clin Oncol. 2011 Feb 20;29(6):755-60. Epub 2011 Jan 24. [Full Text]
- NCI FactSheet: End-of-Life Care for People Who Have Cancer
- Coping with Cancer: Preparing for the End of Life
Photo: Jennifer W. Mack, MD, MPH, Hematologist/oncologist at Dana-Farber/Children' Hospital Cancer Center. Photo Courtesy © Harvard Medical School/Dana-Farber/Children' Hospital Cancer Center 2007.
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