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End-of-life care with doc often occurs too late?
Incurable cancer patients deprived of opportunities
The vast majority of patients with incurable lung or colorectal cancer talk with a physician about their options for care at the end of life, but often not until late in the course of their illness, according to a new study1 by Dana-Farber Cancer Institute, Boston, published in a recent issue of the Annals of Internal Medicine.
The researchers found that such belated conversations tend to occur under particularly stressful conditions, when patients have been admitted to a hospital for acute care. And the doctor who shares in the end-of-life (EOL) care talk is often a hospital physician, rather than an oncologist who has treated the patient for much of his or her illness.
Together, these circumstances might deprive patients of the opportunity for extended reflection and deliberation that would have been possible months earlier, when the conversation also could have occurred under less trying and hectic conditions, the authors suggest.
"Previous studies have shown that patients who discuss their end-of-life care preferences with a physician are more likely to choose palliative, comfort-focused care over aggressive measures, and receive hospice or other care consistent with their wishes," says the study's lead author, Jennifer Mack, MD, MPH, co-director, Pediatric Hematology/Oncology Fellowship Program, Dana-Farber/Children's Hospital Cancer Center. "But studies haven't looked at the timing of these discussions, or where and with whom they occur."
The study, which involved 2,155 patients with stage IV (highly advanced) lung or colorectal cancer, found that 73% percent of the patients had an EOL care talk with a physician, according to medical records or an interview with the patient or a companion. Among the nearly 1,000 patients who passed away and whose records document an EOL care discussion with a physician, the median time of those discussions was just 33 days before death.
Other findings pertain to the location of those discussions and the type of physician involved. Of the more than 1,000 EOL care discussions in medical records, 55% occurred in the hospital. Oncologists documented EOL care talks with only 27% of their terminally ill patients in the study.
Data for the study was provided by the Cancer Outcomes Research and Surveillance Consortium (CanCORS), a multi-region, population- and health system-based study of more than 10,000 patients with lung or colorectal cancer. Researchers interviewed patients at two time points and analyzed their medical records 15 months after diagnosis.
"It's encouraging to see such a high percentage of patients had end-of-life care conversations with a physician," Mack says. "There's a concern, though, that so many of these talks are taking place late in the trajectory of the disease."
Previous studies had estimated that fewer than 40% of patients with advanced cancer had EOL care discussions. Mack theorizes that this lower figure might reflect that earlier studies didn't record EOL talks that took place shortly before patients' death.
Other research has suggested that physicians might delay EOL care discussions because of a natural reluctance to broach the subject or because it conflicts with physicians' problem-solving, hope-giving image. While such motivations are understandable, Mack says, they might work to patients' detriment if they postpone the conversations too long.
Mack and her colleagues are planning future studies to examine the quality and content of EOL care conversations, and then they plan to explore whether having such talks earlier in the course of illness can benefit patients.