Earlier End-of-Life Talk, Less Aggressive Care at the End

Zosia Chustecka

November 13, 2012

In patients with advanced cancer, initiating an end-of-life discussion earlier rather than later led to an increase in hospice care and less-aggressive care in the final days of life, according to a study published online November 13 in the Journal of Clinical Oncology.

The earlier these discussions take place, the better. Dr. Sandra Swain

The study was highlighted in a press release issued by the American Society of Clinical Oncology (ASCO), which reports that this is "the first-of-its-kind scientific evidence that timing of end-of-life discussions affects decisions about end-of-life care."

Dr. Sandra Swain

"Conversations about treatment options for advanced cancer are extremely difficult for patients, their families, and their oncologist. But this study underscores a growing body of evidence that the earlier these discussions take place, the better, because they have a real impact on a patient's quality of life in their final days," ASCO president Sandra Swain, MD, FACP, stated in the press release.

Mostly Lung Cancer Patients

The study, conducted by researchers from the Dana-Farber Cancer Institute in Boston, Massachusetts, involved 1231 patients with highly advanced (stage IV) cancer, mostly lung (82%) but some colorectal cancer.

The researchers found that 88% of these patients (or their surrogates) had end-of-life discussions with their physician, and that 39% of these conversations took place in the final 30 days of life.

In the remaining 61% of cases (where this discussion was held earlier), patients were less likely to receive aggressive care during their final days, with less chemotherapy and less acute care.

Overall, nearly half the study participants received at least 1 form of aggressive care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%).

For patients who opted not to receive any aggressive care at the end-of life, there was a significant difference between the proportion of patients that had the discussion earlier and the proportion that had the discussion later (34% to 45% vs 65%; P < .001).

For patients who had the earlier discussion, the use of hospice care was much higher (68% to 77% vs 49%; P < .001) and was initiated earlier.

"For patients in the final weeks of life, aggressive measures such as chemotherapy usually don't extend life, but they can lower the amount of time that remains," lead study author Jennifer Mack, MD, MPH, said in a statement released by the Dana-Farber Cancer Center.

"Often, when patients understand that additional aggressive treatment doesn't offer much benefit, they choose an option, such as hospice, that focuses on quality of life," she added.

Aggressive treatment at the end of life is not necessarily wrong, but the decision of whether to pursue this option is best made in the relative calm before the last few weeks of life, Dr. Mack explained. Postponing the conversation to the point where a patient's condition is rapidly deteriorating can place the treatment decisions in the hands of the patient's family, rather than the patient, she noted.

Patients were more likely to opt out of aggressive care and choose quality-of-life care if they had the discussion relatively soon after they were diagnosed with incurable cancer.

"Most patients who recognize that their cancer is terminal want to receive less-aggressive care at the end of life," Dr. Mack said.

"Choosing less-aggressive care at the end of life offers benefits for both patients and their care givers," Dr. Mack explained. "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."

"This is also important because studies have shown that aggressive care is associated with a higher risk of depression among the bereaved caregivers of the cancer patient," she added.

However, in practice, aggressive care is still common in the setting of terminal cancer, according to the ASCO press release. This is partly because end-of-life discussions are difficult for both physicians and patients, so they tend to be postponed. This practice continues in spite of the fact that national guidelines, and ASCO's own guidelines, recommend that end-of-life discussions be held soon after the diagnosis of advanced cancer.

This study underscores "a need for national emphasis from ASCO and many other professional and patient groups on advanced cancer care planning in physician education and training programs," the press release notes.

There are a number of current guidelines on end-of life care in patients with advanced cancer (e.g., from the National Comprehensive Cancer Network, the National Consensus Project for Quality Palliative Care, and the American College of Physicians–American Society of Internal Medicine End-of-Life Consensus Panel) in addition to a statement released by ASCO last year.

All current guidelines recommend that discussions about end-of-life care planning begin early in the disease course for patients with incurable cancer, during periods of relative medical stability rather than acute deterioration, and with physicians who know the patient well, the researchers note.

"Our findings suggest that those guidelines are well founded, that patients who have such discussions a month or more before death tend to receive treatment geared toward a good quality of life," said Dr. Mack.

Physicians seem to wait until the patient begins deteriorating medically.

"Physicians seem to wait until the patient begins deteriorating medically," the researchers write. "Instead, physicians should consider moving conversations closer to diagnosis and initiating conversations while the patient is doing comparatively well, so the patient has time to plan for more difficult times in the future," they explain.

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online November 13, 2012. Abstract