COMMENTARY

Should Palliative Chemotherapy Be Used at All?

Betty R. Ferrell, PhD, RN

Disclosures

November 05, 2015

Associations Between Palliative Chemotherapy and Adult Cancer Patients' End of Life Care and Place of Death: Prospective Cohort Study

Wright AA, Zhang B, Keating NL, Weeks JC, Prigerson HG
BMJ. 2014; 348:g1219

Outcomes of Palliative Chemotherapy

Questions about the use of chemotherapy in the final months of life were first initiated by hospice and palliative care communities. Recently, the American Society of Clinical Oncology (ASCO), policy makers, and payers have joined the conversation related to indications, and restrictions needed, for disease-focused therapy in the final months of life.

With this study, Wright and colleagues contribute valuable data to this important clinical issue through their evaluation of meaningful outcomes of continued chemotherapy. The study included 386 patients from eight outpatient oncology clinics who had been identified by their physicians as being terminally ill and who subsequently died.

Just over half (56%) of the enrolled patients were receiving palliative chemotherapy, and these patients were found to have higher rates of cardiopulmonary resuscitation and need for mechanical ventilation, interventions that are consistently cited as not being desirable for quality of life in the final days of life.

Although there were no differences in overall survival between patients who received palliative chemotherapy and those who did not, there was a difference in referral to hospice. Those who did not receive palliative chemotherapy were referred earlier to hospice care, which is commonly accepted as an indicator of quality care in terminal illness.

Another key indicator of quality care showing significant differences in this study was the place of death. Patients receiving palliative chemotherapy were more likely to die in an intensive care unit. This finding reinforces a growing sentiment that continuing disease-focused treatments delays access to things that matter most at the end of life, such as dying in the place one prefers, usually at home.

Viewpoint

This article addresses a very important concern given recent recognition that up to 50% of patients with terminal cancer receive chemotherapy in the final 30 days of life.[1,2] This study shows that the use of chemotherapy in this population is associated with an increased use of aggressive interventions in an intensive care unit.

ASCO has identified reducing chemotherapy use at the end of life among the top five practices that could reduce cost while also improving patient care.[3] Findings of interest in this study include the fact that patients who received chemotherapy were less likely to acknowledge that they were terminally ill or to have discussed their end-of-life wishes with a physician. They were also less likely to have completed a do-not-resuscitate order. Thus, the continued administration of chemotherapy seems to affect the patient's own behaviors and response to the illness.

These study findings prompt attention to the use of palliative chemotherapy in the final months of life. This study is very timely given the ever-increasing emphasis on costs of care at the end of life, the need to respect patient choices, and the recognition that aggressive disease-focused therapies can greatly diminish quality of life at the end of life.[4,5,6]

Abstract

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