More on End-of-Life Care

Research in the Journal of Clinical Oncology describes a study relating to end-of-life discussions and their effect on the aggressiveness of care.    (JClinOnc. Article)    End-of-life care has been singled out by many researchers, including those at the Dartmouth Atlas, for inappropriateness and wide variations that often do not reflect patient preferences.  A body of research suggests that in general patients have greater satisfaction with hospice or at-home care and do not want to be in the hospital at the end-of-life.  Physicians sometimes appear to feel obligated to try every possible method to extend the patient’s life.  Both parties are likely desirous of avoiding frank and open discussions about the patient’s condition and likelihood of survival, but these discussions may be critical to ensure both respect for the patient’s informed wishes and to help slow the growth of health spending.

In the study, about 1230 patients with advanced lung or colorectal cancer who died during the study period were examined in regard to their course of treatment and potential discussion about that care.  Almost half of the patients had at least one marker of aggressive care, including chemotherapy in the last 14 days of life for 16%, intensive care unit stay in the last 30 days of life for 9% and acute hospital-based care in the last 30 days of life for 30%.  But patients who had end-of-life discussions with doctors at least 30 days before they died were significantly less likely to receive any of these aggressive care methods and were much more likely to receive hospice care and to start that hospice care sooner.  It seems obvious now that doctors need to initiate discussions about end-of-life care with any patient who has a serious illness, preferably as early on as possible, and the patient’s preferences should be documented and communicated to all providers.  The sooner patients and doctors face the reality of possible outcomes of an illness, the more likely the patient has a better quality of life to the end, and as a beneficial side effect, the less money the health system spends in an ultimately fruitless attempt to prolong life.