An Opportunity to Make a Difference
Abstract & Commentary
By Kenneth P. Steinberg, MD, FACP, Professor, University of Washington School of Medicine, Seattle, WA. Dr. Steinberg reports no financial relationships in this field of study.
Synopsis: The majority of patients with advanced cancer have decisional capacity at the time of their terminal hospitalization but lose that capacity before having an end-of-life discussion. Surrogate decision-makers are then more likely to request mechanical ventilation and other aggressive measures than the patients who made their own decision. Hospitalists have a unique opportunity to make a difference in end-of-life care for these patients by engaging in these discussions before patients lose decisional capacity.
Source: Zaros MC, Curtis JR, Silveira MJ, Elmore JG. Opportunity lost: End-of-life discussions in cancer patients who die in the hospital. J Hosp Med 2013;8:334-340.
The majority of patients with serious illness die in the hospital, but end-of-life discussions are known to be associated with a decrease in the use of aggressive life-sustaining treatments, improved quality of life, and reduced costs of care. Conducting these conversations in the hospital setting presents several challenges, including whether patients have decisional capacity due to their acute or progressive chronic disease. Once patients lose decisional capacity, discussions are instead held with surrogate decision makers. It was previously unknown what the association was between patient and surrogate participation in end-of-life discussions at the time of terminal hospitalization and end-of-life treatments received.
This was a retrospective cohort study of consecutive adult patients with advanced cancer who died in the hospital over a 4-year time period. Data were abstracted by review of the medical record using a comprehensive chart abstraction tool that was based on a previously validated instrument. Decisional capacity assessment was determined from the first 24 hours of admission. End-of-life care discussions were also noted in the chart abstraction. The authors then compared those patients with and without decisional capacity on admission, and those with decisional capacity who did and did not participate in end-of-life discussions. They then looked to see if documentation of a decision about end-of-life care was associated with life-sustaining and palliative treatments received during that hospitalization.
The study consisted of 142 patients. Twenty-seven (19%) were considered not to have decisional capacity while 115 patients (79%) were considered to have decisional capacity. These groups were similar in age, gender, and types of cancer, as well as in the number of DNR orders established prior to admission. Of the 115 patients with decisional capacity, 56 (48.7%) participated in end-of-life discussions with the medical team during the terminal hospitalization. Forty-six of the remaining 59 lost decisional capacity prior to a conversation and the end-of-life discussions were held instead with a surrogate or were never held.
Life-prolonging treatments were more likely to be used for patients whose end-of-life discussions were held by a surrogate in contrast to those patients who participated in those discussions themselves. Patients who had conversations held by surrogates were more likely to receive ventilator support (56.5% vs. 23.2%, P < 0.01), chemotherapy (39.1% vs. 5.4%, P < 0.01), artificial nutrition or hydration (45.7% vs. 25.0%, P = 0.03), antibiotics (97.8% vs. 78.6%, P < 0.01), and ICU treatment (56.5% vs. 23.2%, P < 0.01) when compared to patients who participated in their own endof-life care discussions. Patients who lost decisional capacity and required a surrogate decision-maker to participate in end-of-life discussions also had longer length of stay (15.8 vs. 10.3 days, P = 0.03) and length of time until end-of-life discussions (14.0 vs. 6.1 days, P < 0.01).
While this is an observational cohort study, and thus is unable to determine causality, it seems quite clear that the ability of patients with advanced cancer to participate in their own discussions about end-of-life care during their terminal hospitalization is associated with lower rates of aggressive life-sustaining treatments and longer lengths of stay. Strengths of the study include the use of a standardized, validated chart abstraction tool, and the statistical methodology was sound. Weaknesses of the study include that it relies inherently on retrospective chart review and the quality of the documentation by healthcare providers in the medical record. Thus discussions could have been held and not documented, and inferences of decisional capacity based on notes may or may not have been accurate. Nevertheless, the study is consistent with much of the literature in this area. It thus seems to me that it is important to engage our terminally ill patients in a compassionate and supportive manner regarding their end-of-life care wishes. This study identifies a group of hospitalized patients with advanced cancer who could benefit from improved end-of-life communication before they lose the ability to make their own healthcare decisions, forcing the burden of these decisions on surrogate decision makers. The prospect for improvement comes from an important window of opportunity to increase the concordance between patients’ wishes for care at the end-of-life and the care that we actually deliver. As hospitalists, we can do this. We should not let this be an opportunity lost.