Aggressive Treatments at End of Life Linked to Worse Quality of Death for Cancer Patients

Laurie Barclay, MD

May 03, 2007

May 3, 2007 — For patients with advanced cancer, aggressive treatment in the last week of life is linked to a worse quality of death and less likelihood of dying in the place of the patient's choice, according to a presentation on May 3 at the American Geriatrics Society (AGS) annual meeting in Seattle, Washington.

"We found that the greater the number of aggressive treatments these advanced cancer patients received in their last week of life, the more psychological and physical distress they experienced, as reported by family members or nurses who were with them at that time," presenter and lead author Gabriel K. Silverman, MS, an MD/PhD student at the Department of Social and Decision Sciences, Carnegie Mellon University, and the University of Pittsburgh School of Medicine in Pennsylvania, told Medscape. "Of patients who received no aggressive treatments in the days preceding their death, nearly 90% died in their preferred location, while this was true of only about a third of patients receiving two or more of these treatments. We found the reverse pattern of outcomes associated with duration of hospice use."

As part of the Coping with Cancer study, 243 advanced cancer patients and their caregivers were interviewed. After the patient's death, the primary informal caregiver (e.g., spouse or adult child) or formal caregiver (e.g., nurse) most knowledgeable about the patient's last week of life reported which aggressive treatments the patient received during that week. Aggressive treatments were defined as intensive-care-unit stay, ventilator support, resuscitation, feeding tube, nonpalliative chemotherapy, and antibiotics. Outcome measures included the duration of hospice care received and various measures of quality of death.

After adjustment for the patient's sex, age, race, and the source of the report (informal or formal caregiver), the number of aggressive treatments received in the last week of life was associated with more psychological distress (P = .003), more physical distress (P < .0001), a lower overall quality of death (P = .03), and a lower probability of dying in the patient's preferred place (P < .0001).

In contrast, receiving a longer duration of hospice care was associated with less physical distress (P < .0001), a higher overall quality of death (P = .01), and a greater probability of dying in the patient's preferred place (P < .0001), after adjustment for the variables listed above.

"The more time patients spent under hospice care, the greater their quality of death," Mr. Silverman said. "For example, patients who received at least 5 weeks of hospice care were in less physical distress in their last week of life than those who lived less than a week with hospice, and those who received no hospice at all were in the most physical distress at the end of their lives. These results suggest that when patients are actively dying, the use of aggressive treatments should be considered with caution and only pursued with the full understanding of patients or their surrogate decision makers."

A limitation of this study is that it cannot determine causality, according to Robert M. Arnold, MD, the Leo H. Criep Chair in Patient Care and Chief, Section of Palliative Care and Medical Ethics at the University of Pittsburgh School of Medicine. Dr. Arnold was not directly involved in this study but provided independent commentary for Medscape.

"This study shows an association between aggressive treatment and psychological and physical distress, but that might be because people who are more distressed ask for more treatment, rather than because the treatment itself is causing distress," Dr. Arnold said. "More research is clearly needed, as is greater use of palliative care doctors at the end of life."

Mr. Silverman pointed out that discussions about prognosis, goals of care, and treatment preferences, including the option of hospice care, should occur with more patients and earlier in the course of the disease. His group is now prospectively evaluating whether doctor-patient communication predicts aggressiveness of care at the end of life, and whether these treatments, in turn, affect the bereavement adjustment of close family members.

"As a doctor, if I had a patient or family who wanted aggressive, life-sustaining care toward the end of their life, I would view it as a red flag warning of patient or caregiver distress," Dr. Arnold concluded. "Often patients and their families are suffering, sad, or distressed at the end of life, and when dying occurs in medical settings they may hope that aggressive treatment will help the suffering, but often it doesn't."

The National Institute of Mental Health, National Cancer Institute, a predoctoral National Institutes of Health training grant in aging research, and the Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, supported this study. Mr. Silverman and Dr. Arnold report no relevant financial relationships.

AGS 2007 Annual Scientific Meeting: Abstract P4. Presented May 3, 2007.

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