Among family members of older patients who died of advanced-stage cancer, earlier hospice enrollment, avoidance of ICU admissions within 30 days of death, and death occurring outside the hospital were associated with perceptions of better end-of-life care, according to a recent study.1
Researchers used information obtained from interviews with family members of Medicare patients with advanced-stage lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance study who died by the end of 2011. Some key findings include the following:
- Of 1,146 patients with cancer, bereaved family members reported excellent end-of-life care for 51%.
- Family members reported excellent end-of-life care more often for patients who received hospice care for longer than three days (59%) than those who did not receive hospice care or received three or fewer days (43%).
- In contrast, family members of patients admitted to an ICU within 30 days of death reported excellent end-of-life care less often (45%) than those who were not admitted to an ICU within 30 days of death (52%).
- Family members of patients who died in the hospital reported excellent end-of-life care less often (42%) than those who did not die in the hospital (57%).
- Family members of patients who did not receive hospice care or received three or fewer days were less likely to report that patients died in their preferred location (40%) than those who received hospice care for longer than three days (73%).
“Patients with advanced-stage cancer are receiving increasingly aggressive medical care near death, despite growing evidence that high-intensity treatments may not be associated with better patient quality of life, outcomes, or caregiver bereavement,” says Alexi Wright, MD, the study’s lead author. Wright is an assistant professor of medical oncology at Dana-Farber Cancer Institute in Boston.
Several quality measures for end-of-life care have been endorsed by medical and policy groups, including the American Society for Clinical Oncology and the National Quality Forum. “But few studies have examined whether these measures reflect patients’ preferences or bereaved family member’s perceptions of the quality of end-of-life care,” says Wright.
Existing measures characterize the repeated use of emergency department visits near death as poor quality of care. “However, we did not observe a difference in family-reported ratings by this measure,” says Wright. The lack of validation of this indicator suggests that some aggressive care measures may be less salient to patients and families, adds Wright.
“Our findings suggest that efforts to increase earlier hospice enrollment and avoidance of ICU admissions and hospital deaths might improve the quality of end-of-life care,” says Wright.
Possible approaches include enhanced counseling of patients and families, early palliative care referrals, and an audit system to monitor physicians’ use of aggressive end-of-life care.
“These might result in the provision of more preference-sensitive care for patients, and overall improved quality of end-of-life care,” says Wright.
REFERENCE
- Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA 2016; 315 (3): 284-292.
SOURCE
- Alexi Wright, MD, MPH, Assistant Professor, Medical Oncology, Dana-Farber Cancer Institute, Boston, MA. Phone: (617) 632-2334. Fax: (617) 632-3479.
