End-of-life discussions with physicians have benefits

Hospice enrollment is sooner

According to a recent study,1 terminally ill patients who had end-of-life discussions with physicians had earlier hospice enrollment (65.6% vs. 44.5%), compared to patients who did not have these discussions. Also, longer hospice stays were associated with better patient quality of life, while more aggressive medical care was associated with worse patient quality of life.

Also, patients who had the end-of-life discussions were not more likely to experience emotional distress, compared to patients who did not have those discussions.

End-of-life discussions give patients the opportunity to define their goals and expectations for the medical care that they want to receive near death. "But these discussions also mean confronting the limitations of medical treatments and the reality that life is finite, both of which may cause psychological distress," the authors wrote.

Physicians and patients are ambivalent about talking about death and often avoid these conversations, they write. "To date, however, research has not examined whether these discussions are associated with patients' psychological distress or medical care near death," the authors state. "Without this information, physicians cannot weigh the risks and benefits of end-of-life discussions."

Alexi A. Wright, MD, hematology-oncology fellow at the Dana-Farber Cancer Institute, Boston, and colleagues examined the associations between end-of-life discussions with physicians and the medical care that terminally ill patients receive near death. The study included patients with advanced cancer and their informal caregivers (n = 332 pairs). Patients were followed up from enrollment to death, a median (midpoint) of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later. Of 332 patients, 123 (37%) reported having end-of-life discussions with their physicians.

The researchers found that such discussions were not associated with higher rates of major depressive disorder or more worry, but those patients received significantly fewer aggressive medical interventions near death: lower rates of ventilation (1.6% vs. 11%), resuscitation (0.8% vs. 6.7%), and ICU admission (4.1% vs. 12.4%).

Patients who reported engaging in those conversations were significantly more likely to accept that their illness was terminal, prefer medical treatment focused on relieving pain and discomfort over life-extending therapies, and have completed a do-not-resuscitate order.

Caregivers of patients who received any aggressive care were at higher risk for developing a major depressive disorder, experiencing regret, and feeling unprepared for the patients' deaths, compared with caregivers of patients who did not receive aggressive care. They also had worse quality-of-life outcomes, including overall quality of life, self-reported health, and increased role limitations. Better patient quality of life was associated with better caregiver quality of life at follow-up.

"Our results suggest that end-of-life discussions may have cascading benefits for patients and their caregivers," the authors wrote. Despite physicians' concerns that patients might experience psychological harm due to end-of-life discussions, the authors 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." the authors wrote.

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

Reference

  1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008; 300:1,665-1,673.