Emails Help Doctors Note End-of-Life Preferences

Fran Lowry

January 10, 2013

Having end-of-life discussions in a calm nonurgent situation is preferable to having these discussions at a time of crisis.

A new study, published online January 2 in the Journal of Clinical Oncology, showed that a simple email reminder was effective in encouraging oncology physicians to initiate such talks.

The study was led by Jennifer Temel, MD, from the Massachusetts General Hospital in Boston, who headed a previous ground-breaking study that showed that the early introduction of palliative care to patients with advance lung cancer improved survival (N Engl J Med. 2010;363:733-742).

Building on that work, the researchers set out to document the preferences of patients with advanced lung cancer for end-of-life care at an earlier stage of treatment.

"Our study shows that it is feasible to alter physician behavior and to have them discuss and document patients' preferences more often and earlier in the course of disease," Dr. Temel said, adding that further research to improve decision making about end-of-life care is "imperative."

Difficult Conversations

Code status documentation — noting a patient's preference for life-sustaining or heroic measures should they experience a life-threatening event — is important for patients with incurable cancers, Dr. Temel told Medscape Medical News.

Oncologists often find it difficult to initiate end-of-life discussions with their patients who have advanced disease. However, deferring or delaying such discussions has negative implications for both cancer patients and society as a whole, Dr. Temel noted.

"Documenting these preferences in a nonacute, nonurgent setting, such as the outpatient setting, is preferable so that the options for care can be discussed calmly, as opposed to in an emergency room or while someone is very sick and in the hospital, when it is harder to consider the options thoughtfully and clearly," she explained.

"Patients with advanced cancer who do not recall discussing their end-of-life care goals are significantly more likely to receive aggressive medical care, start hospice services later in the course of disease, and lack a documented code status. Patients who recall having these conversations have significantly lower healthcare costs in the final week of life, when the majority of healthcare expenditures occur," she said.

"Forbidden Topics"

Death and dying remain forbidden topics, writes palliative care specialist Jamie H. Von Roenn, MD, from the Northwestern University Feinberg School of Medicine in Chicago, Illinois, in an accompanying editorial.

"Conversations about end-of-life preferences are difficult for everyone, even more so because physicians do not receive adequate training in communication skills," Dr. Von Roenn notes.

National guidelines recommend that physicians initiate such discussions when the estimated prognosis is less than a year. However, "because we all tend to do what is most comfortable on the basis of our training, it is not surprising that many oncologists prefer to delay the often difficult conversations regarding code status or hospice care until there are no nonpalliative treatment options remaining," she explains.

Email Reminders

In their 2-phase study, Dr. Temel and colleagues first met with focus groups of oncology physicians and nurses who care for patients with advanced cancer. After hearing their suggestions, the researchers decided that email would be the best way to prompt them to document outpatient code status.

The email reminders were timed to be given at the start of each patient's new chemotherapy regimen.

The researchers then asked 100 patients with incurable lung cancer to participate in the study, and compared them with a cohort of 100 consecutive historic control subjects who began therapy for incurable lung cancer at least 1 year before the start of the study.

Patients in the intervention group were more likely than those in the control group to have a code status documented in their outpatient electronic health record.

After a year, more patients in the intervention group than in the control group had a code status documented (33.7% vs 14.5%; P = .003). In addition, the mean time to code-status documentation was significantly shorter for those in the intervention group (8.6 vs 10.5 months; P = .004).

The majority of patients in both groups who had a documented code status chose to not to be resuscitated, although more patients in the intervention group than in the control group recorded that choice (29.6% vs 12.0%; P = .006)

Need for Training

In her editorial, Dr. Von Roenn notes that more than half a million Americans died of cancer in 2011, and most had no documentation about their preferences for end-of-life care, particularly with regard to resuscitation.

"The majority of the discussions that elicit preferences for resuscitation occur in the hospital without time for thoughtful discourse. One large cancer hospital reported that 86% of patients who died in the hospital had a documented do-not-resuscitate order. This is an encouraging statistic until one recognizes that the median time between signing the order and death was 0 days," she writes.

Dr. Von Roenn adds that training physicians how to communicate with their oncology patients about end-of-life and palliative care is imperative.

"System changes such as the one described...are necessary, but without adequate physician communication skills, such changes are insufficient to provide patients with the opportunity to voice their concerns and values about end-of-life care and their preferences for specific medical interventions," she concludes.

The study was supported by the American Cancer Society and gifts from the Thoracic Oncology Quality of Life Fund. Dr. Temel has disclosed no relevant financial relationships. Dr. Von Roenn reports being a consultant or advisor for and receiving honoraria from Archimedes and AstraZeneca.

J Clin Oncol. Published online January 2, 2013. Abstract, Editorial