Earlier end-of-life discussions lead to less aggressive care later on


The latest evidence assures that sooner really is better, especially regarding end-of-life (EOL) discussions.

Published in the Nov. 13 edition of the Journal of Clinical Oncology, a new study finds that care discussions conducted prior to the last 30 days of life accounted for far more infrequent employments of chemotherapy within the final 14 days of life as well as lower uses of acute or ICU care in the final 30 days of life.

“Research has shown that choosing less aggressive care at the end of life offers important benefits for both patients and their caregivers. Patients have a better quality of life in their final days because there is a greater focus on symptom management, and they are more often able to receive care in their homes,” said lead author Jennifer W. Mack, MD, MPH , a pediatric hematologist/ oncologist at Dana-Farber/Children' Hospital Cancer Center, in a news release. “This is also important because studies have shown that aggressive care is associated with a higher risk of depression among bereaved caregivers of cancer patients.”

Researchers followed discussion patterns regarding hospice and resuscitation options for 1,231 patients with end-stage lung or colorectal cancer, either in person (through a surrogate if the patients were deceased or too ill to contribute) or through their medical records.

According to the study: “Nearly half of all the study participants received at least one form of aggressive care, including chemotherapy in the last 14 days of life, intensive care unit (ICU) care in the last 30 days of life, and acute, hospital-based care in the last 30 days of life. However, compared with cases where EOL discussions took place within the last 30 days of life, cases with earlier EOL discussions were associated with less frequent use of aggressive care (34-45 percent vs. 65 percent) and increased use of hospice care (68-77 percent vs. 49 percent).”

With such proof, physicians should be moved for both their sake and in the best interest of their patients to have EOL discussions as soon as the possibility of fatality becomes a reality.

“Physicians should remember to start having the discussion about end of life issues or end of life care very early on once a patient is diagnosed with advanced disease because it’s a process,” Sandra M. Swain, MD, FACP, president of the American Society of Clinical Oncology, told PhysBizTech. “And patients don’t really hear it all in the beginning, but you really need to have that discussion when you know that a patient is going to basically die of their disease eventually. You really do owe it to them to start discussing it very early on and I think that’s what’s brought out in this paper, that unfortunately the discussion came very late in many of the situations and it was usually in an acute kind of crisis situation, where the patient was in the hospital in the last 30 days of their life.”

“It’s a much better situation for everyone [when EOL talks take place earlier], even for the physicians because they’re not in a crisis situation again, trying to explain to the patient why they’re not going to make it and it’s going to be soon,” Swain added.

To facilitate effective EOL discussions, the key is to not only begin early, Swain said, but to also make sure patients are listening by encouraging them to ask questions and by being persistent. Ask patients, after conversing over such topics, if they understand the prognosis, what the goal of treatment is, if they know how to manage their symptoms, and whether or not they plan to pursue palliative care options. At first, patients “don’t hear you, they don’t want to hear you” — but by asking these questions, the patient can begin to comprehend the prognosis in their own terms well as from the perspective of their provider. 

“It’s a process,” Swain concluded. “Patients need to trust the physician, they need to have a good relationship, they need to understand that we both have the same goal [the patient and the doctor] to make the best quality of life possible.”

Swain suggested physicians pursue resources like those found on Cancer.Net; she also encouraged investigation into movements like the Choosing Wisely Campaign.

“Many doctors can’t have these discussions and it’s very obvious in this paper that they didn’t do it well, because physicians are trained to cure and take care of things and I think it’s hard for them to make that transition in their mind that they’re not going to cure this patient,” Swain said.

But with a little practice, both patients and physicians can come to peace with the evolution of both their roles.

The study in its entirety can be found here.

 

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