End-of-Life Care Discussions

Nothing is harder for patients or physicians than recognizing and accepting that a patient is likely to die of a disease.  The desire to be optimistic and to avoid unpleasant subjects makes it hard for both to acknowledge that the end is near.  But there may be no more important task in medicine because it is the patient’s opportunity to decide how they want to live their last few months or weeks and the choice can have very important consequences for the quality of life and even outcomes like survival time.  Past research has shown that discussions about this end-of-life care often don’t occur or happen too late to make a meaningful difference, and new research reported in the Annals of Internal Medicine explores this topic further.   (Annals Article)  The research covered 2155 patients with stage IV lung or colorectal cancer and examined whether and when the patients had end-of-life care discussions, by conducting patient and surrogate discussions and looking at medical records.

Altogether, 73% of these patients had an end-of-life discussion reported by at least one source.  Patients who died during the follow-up period were more than twice as likely to have had such a conversation than those who didn’t die. Over half these discussions occurred in the hospital during acute care, which is not the best or preferred setting.  Among those patients who died, the conversations occurred a relatively short average of 33 days before death, which is not really enough time for patients to adequately plan for their final stage of life.  Only about a fourth of the discussions took place with oncologists, as opposed to other providers, which can be a problem because oncologists often have the best perspective on the patient’s course of disease and likely survival time.   An interesting methodological problem is that there was a significant discordance both ways on what patients and surrogates reported and medical records contained in regard to the presence of end-of-life discussions.  The research suggests that while end-of-life discussions are happening, there is large room for improvement in setting, timing and personnel conducting the conversation.