Psychosocial Needs Matter Most at the End of Life

Megan Brooks

July 09, 2012

July 9, 2012 — Physicians can help terminally ill cancer patients have a better quality of life in their final days by helping to ease their worries, encouraging contemplation, integrating pastoral care into medical care, fostering a relationship based on respect and trust, and preventing unnecessary hospital stays or aggressive futile procedures, according to a study published online July 9 in Archives of Internal Medicine.

Dr. Holly Prigerson

"Physicians who claim that there is little that they have to offer their dying patients should realize that their willingness to be present and not abandon their patients matters a tremendous amount to the quality of life of patients," said study author Holly G. Prigerson, PhD, director of the Center for Psychosocial Epidemiology and Outcomes Research at the Dana-Farber Cancer Institute in Boston, Massachusetts.

"In the end, what matters most to patients is that their psychosocial needs are met. When cure is not an option, care should imply psychosocial and spiritual care and concern," Dr. Prigerson told Medscape Medical News.

This study, she explained, "speaks to the importance of maintaining a therapeutic bond between patient and provider. Patients who want to have a better quality of life in the final stage of their illness should avoid intensive medical care, opt out of the next round of presumably 'life-prolonging therapy,' strive to worry less, pray, and meditate more," Dr. Prigerson said.

Issue Understudied

The concept of quality at the end of life in cancer patients has been "underexamined in cancer medicine in the quest to develop newer, more advanced, and effective modalities of interventional cytotoxic therapies," according to an accompanying commentary.

"It is surprising at this stage in the development and implementation of complex multimodal cancer treatment strategies that the factors most critical in influencing the quality of the end of life are not clearly defined and considered along the entire timeline beginning with cancer diagnosis," write Alan B. Zonderman, PhD, and Michele K. Evans, MD, both from the National Institute on Aging, Biomedical Research Center in Baltimore, Maryland.

They say the study by Dr. Prigerson and colleagues has "provided important insights" on this topic.

The study involved 396 patients with advanced cancer and their family caregivers enrolled in the Coping With Cancer Study, a federally funded multicenter prospective longitudinal cohort study, conducted in the United States, looking at the quality of care patients receive at the end of life. The patients were followed from enrollment (from September 1, 2002 to February 28, 2008) to death; median follow-up was 4.1 months. Average patient age was 58.7 years.

Patients and caregivers provided various demographic, medical, and psychosocial data at enrollment. Several weeks after the patient died, caregivers retrospectively rated the quality of life just before death.

Using random-effects modeling and cross-validation techniques, the researchers identified several key predictors of informant-rated quality of life at the end of life.

They note that 2 of the most important determinants of poor end-of-life quality of life are dying in a hospital and having a stay in the intensive care unit in the final week of life. "Therefore, attempts to avoid costly hospitalizations and to encourage transfer of hospitalized patients to home or hospice might improve patient quality of life at the end of life," the researchers note.

Chemotherapy and feeding tube use were also linked to poorer quality of life, so "limiting these types of aggressive end-of-life care may be an effective strategy as well," they point out.

Patient worry at baseline was also a key predictor of worse quality of life at the end, indicating that efforts to curb patient anxiety should be a "top priority" for care aimed at enhancing end-of-life quality of life, the researchers say.

On the flip side, religious prayer, meditation, and pastor care services in the clinic or hospital were significantly associated with better end-of-life quality of life. "These findings are consistent with other studies that have shown significant associations between spirituality and peacefulness and quality of life in patients with life-threatening diseases," the researchers note.

Doctor–Patient Bond, Communication Key

In addition, patients who felt a strong "therapeutic alliance" with their physician had a better quality of life at the end. Measures of therapeutic alliance looked at patient belief that they were being treated with respect and as a whole person by their physician, patient trust in and respect for their physician, and patient comfort in asking their physician about their care, the researchers explain.

These results, they note, "suggest that physicians who are able to remain engaged and 'present' for their dying patients — by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings — have the capacity to improve a dying patient's quality of life."

Perhaps that's easier said than done. Although physician–patient communication is a "cornerstone" of high-quality medical care in all facets of medicine, "in the highly emotional setting often present when caring for patients with advanced cancer, these channels of communication are stressed," Drs. Zonderman and Evans write in their commentary.

They cite a study that found that physicians, on average, had poor skills when it came to handling emotions and only moderate skills when it came to discussing end-of-life issues (J Palliat Med. 2010;13:949-956). "Failure of these channels of communication and undefined, incompletely developed partnerships between patient and physician or other care providers likely frequently result in provision of care that ultimately negatively affects the quality of the end of life," Drs. Zonderman and Evans explain.

Support for ASCO Statement

Dr. Prigerson told Medscape Medical News that "what makes this study unique is that it is the first to empirically determine what factors matter most to a patients' quality of life near death." These factors are "promising targets for healthcare interventions to improve the quality of life of dying patients," she and her colleagues note.

They emphasize that their study is constrained by the data available and that even the best models explained less than 20% of the variance in the end-of-life quality of life, "leaving much to learn about other influences on this outcome."

Drs. Zonderman and Evans note that a statement from the American Society of Clinical Oncology (ASCO), previously reported by Medscape Medical News, argues that the paradigm of care must change and that this change must include "the very areas" identified by Dr. Prigerson and colleagues.

The study was supported in part by grants from the National Institute of Mental Health, the National Cancer Institute, and the Center for Psychosocial Epidemiology and Outcomes Research at the Dana-Farber Cancer Institute. The study authors, Dr. Zonderman, and Dr. Evans have disclosed no relevant financial relationships.

Arch Intern Med. Published online July 9, 2012. Abstract, Commentary

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