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22-02-2012 | Legal medicine | Article

End-of-life care discussions occur late for patients with advanced cancer

Abstract

Free abstract

MedWire News: More than half of discussions about end-of-life care occur during acute hospital treatment, and they tend to occur at a late stage of illness in patients with terminal cancer, shows research published in the Annals of Internal Medicine.

Jennifer Mack, of the Dana-Farber Cancer Institute in Boston, Massachusetts, USA, and colleagues found that of 2155 patients with stage IV lung or colorectal cancer, 73% discussed end-of-life care with a physician before they died. However, of the 1081 first discussions documented, 55% occurred during acute hospitalization.

"National guidelines recommend that physicians discuss end-of-life (EOL) care planning with patients who have incurable cancer and a life expectancy of less than 1 year," explain Mack and team. "Patients who have discussed their preferences for EOL care with a physician are more likely to choose palliation over aggressive measures at EOL, to die at home or under hospice care, and to receive care that is consistent with their preferences."

The researchers interviewed patients, or a surrogate if they were too ill, at two time points after diagnosis: approximately 4-6 months after diagnosis and 15 months after diagnosis.

Of the 959 patients who died during the follow-up period, their first EOL discussion took place a median of 33 days before death (ranging between 13 and 75 days). The researchers point out that this contrasts with the early EOL discussion recommendation issued in US guidelines.

They also found that most of the EOL discussions were conducted by medical oncologists (49%), but also by general medical physicians (36%), palliative care physicians (6%), other medical specialists (7%), radiation oncologists (4%), surgeons (3%), and other providers (0.5%). However, medical oncologists reported having EOL care discussions with only 27% of their patients.

Mack and colleagues point out that past research has found that physicians avoid EOL discussions until death is imminent, which is assumed to be due to avoidance of a difficult matter. However, this study identifies some other possible explanations for late EOL discussion. First, it found that most discussions occurred in hospital, which the researchers say suggests "that acute medical deterioration, and not the diagnosis of incurable cancer, triggers physicians to talk about EOL care."

Second, Mack and co-workers found that most discussions with general medicine physicians occurred in an inpatient setting, which suggests "that these were hospital-based physicians and not those providing longitudinal primary care."

But they add: "Physicians involved in longitudinal care, however, may be best informed about the patient's prognosis and disease trajectory and best equipped to have meaningful discussions about the patient's values and goals."

By Chloe McIvor

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