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Research Review

Earlier End of Life Care Discussions Linked to Less Aggressive Care in Final Days

A large population- and health systems-based prospective study reports earlier discussions about end of life (EOL) care preferences are strongly associated with less aggressive care in the last days of life and increased use of hospice care for patients with advanced cancer. The study, published in the Journal of Clinical Oncology, provides the scientific evidence that timing of EOL care discussions affects decisions about EOL care.

The findings suggest that initiating discussions before the last month of life provides the patients opportunity to make decisions regarding their EOL care preferences in a way that late discussions don’t seem to do. Patients need time to process the information with their family and make good plans based on that information.

National guidelines recommend that oncologists initiate discussions about EOL care soon after a diagnosis of advanced cancer in order to ensure care aligns with patient goals and wishes. Current guidelines state that conversations should happen “during periods of relative medical stability rather than acute deterioration, and with physicians that know the patient well.” In addition, the American Society of Clinical Oncology’s own recommendations for patients with advanced cancer include prioritizing discussions related to advanced cancer care preference upon diagnosis.

“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,” says lead author Jennifer W. Mack, MD, MPH, a pediatric hematologist/oncologist at Dana-Farber/Children' Hospital Cancer Center. “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.”

In the study, investigators identified discussions about hospice and resuscitation from with 1,231 patients (or surrogates of patients who were deceased or too ill to participate) with end-stage lung or colorectal cancer and via review of their medical records. They found that, on average, EOL discussions were initiated 33 days before death and 39% of those discussions occurred within the last 30 days.

Nearly one-half of all the study participants received at least one form of aggressive care, including chemotherapy in the last 14 days of life, 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% to 45% vs. 65%) and increased use of hospice care (68% to 77% vs. 49%).

“Most patients who recognize that their cancer is terminal want to receive less aggressive care at the end of life,” says Mack. However, aggressive care is still common in this setting, in part because discussions about the end of life are often postponed because they are difficult for both physicians and patients. This study also found that 17% of patients or surrogates did not recall EOL care discussions even though they were documented in the medical records, suggesting they may not have fully comprehended the content of the discussion.

— Source: American Society of Clinical Oncology