CANCER study: Physicians and end-of-life discussions

Physicians don't discuss EOL within guidelines

Most physicians reported in a national survey that they would discuss end-of-life options with a terminally ill patient only when there were no more treatments to offer that patient, not when the patient still was feeling well, according to a study published online in CANCER, a peer-reviewed journal of the American Cancer Society.1

Based on other studies that suggest cancer patients receive a lot of aggressive care at the end of life, and through their own experiences treating cancer patients, the designers of the study were "suspicious that doctors might not be talking about end-of-life issues," Nancy L. Keating, MD, MPH, an author of the study and a member of the Department of Health Care Policy, Harvard Medical School, Boston, and the Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, both in Boston.

Also, the researchers took a cue from other literature, which suggests that many patients really don't know how sick they are, she says. "We were quite surprised to find such low rates of discussion of some of these end-of-life issues in patients [who] had a life expectancy of four to six months," Keating notes.

National end-of-life guidelines usually recommend that such end-of-life discussions take place when a patient has less than a year to live, she explains.

The researchers, Keating says, believe there are two possible explanations: One is that physicians aren't aware of these national guidelines; the other is that they are aware of the guidelines but disagree with them. It is possible, she says, that physicians often decide on their own that their patients aren't ready to discuss the end of life, or they believe that patients won't take the prognosis or discussion well, and as a result they will lose hope and give up.

"I personally think that patients have a right to have these discussions early, when they're really able to and capable of [understanding]," Keating says. "But there aren't, and there haven't been, excellent studies randomizing people to hearing about [these matters] early or late to know what happens."

Difficult conversations are, well, difficult

One explanation for why physicians don't have end-of-life discussions with their patients is that these are difficult conversations to have, Keating says.

"Unfortunately, we didn't know what our results would be to have follow-up questions on that, so we can't tell you anymore about that," Keating says. "We need more research to try to find out why doctors aren't having these discussions."

Keating suggests that the best guess for why they aren't having these discussions is that doctors tend to focus on treatment. One finding from the survey was that 66% of physicians surveyed discussed prognosis early, or when the patient had four to six months to live. "So, we said, are doctors using this as an opportunity to have other discussions about hospice and DNR status, etc.?" she says. "And in fact, there were no differences in the rates of doctors discussing these other things who did or did not discuss prognosis early, which leads us to think that the prognosis is a discussion that the doctors use as an opportunity to discuss treatment."

"They might say, 'Well, the average person might live for six months with your condition; but if we treat you with this drug, the average person will live for eight months," Keating says.

Because most of the doctors indicated they would not discuss end-of-life options with the patient unless there were no more treatments to offer, Keating takes issue with that approach. "In patients with metastatic disease, what does it really mean that there are no more treatments to offer? I mean, none of the treatments are curative in the cancers that were studying, or pretty much none. So, most of these patients really do have relatively few options, and I think they may not be understanding that any treatment for them is not going to be curative."

Often, when these conversations are delayed, Keating says that in her experience, the patient receives chemotherapy, then the patient becomes sick from chemotherapy and goes to the hospital, where he or she is intubated due to pneumonia. Keating maintains that "if the patient really understood their prognosis, they might not want that."

Reference

1. Keating NL, Landrum MB, Rogers SO Jr., et al. Physician factors associated with discussions about end-of-life care. CANCER 2010; 116:998-1,006.