Earlier discussions about end-of-life 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, according to a large population- and health systems-based prospective study.
Researchers said the study provides the first 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 an opportunity to make decisions regarding their EOL care preferences in a way that late discussions apparently do not. Patients need time to process the information with their family and make plans based on that information.
National guidelines recommend that oncologists initiate discussions about EOL care soon after a diagnosis of advanced cancer to ensure care aligns with the patients goals and wishes, according to a news release from the American Society of Clinical Oncology. The 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, the ASCOs 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,” Jennifer W. Mack, MD, MPH, the studys lead author and a pediatric hematologist/oncologist at Dana Farber/Childrens Hospital Cancer Center, said in the news release. “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 with 1,231 patients (or surrogates of patients who were deceased or too ill to participate) with end-stage lung or colorectal cancer 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 study participants received at least one form of aggressive care, including chemotherapy in the last 14 days of life, 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 percent) and increased use of hospice care (68-77% vs. 49%).
“Most patients who recognize that their cancer is terminal want to receive less aggressive care at the end of life,” Mack said. However, the researchers also found that 17% of patients or surrogates did not recall EOL care discussion even though they were documented in the medical records, suggesting they might not have fully comprehended the content of the discussion. The authors emphasized 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 researchers said, the study underscores a need for a national emphasis from the ASCO and other professional and patient groups on advanced cancer care planning in physician education and training programs.
The study appeared Nov. 13 on the website of the Journal of Clinical Oncology. A PDF of the study is available at www.jco.ascopubs.org/content/early/2012/11/13/JCO.2012.43.6055.full.pdf.