Many Seriously Ill Hospital Patients Would Trade Survival Time to Avoid Aggressive Treatment

By Lisa Rapaport

April 13, 2020

(Reuters Health) -- The vast majority of hospitalized patients with serious illnesses may be willing to trade at least one year of a five-year lifespan to avoid a scenario in which they died in the ICU with pain and suffering at the end of life, a prospective cohort study suggests.

The study enrolled 180 patients 60 years and older with serious oncologic, cardiac, and pulmonary illnesses who were hospitalized at the Hospital of the University of Pennsylvania in Philadelphia in 2015 and 2016.

Patients were presented with a survival time trade-off question asking them to imagine they would live up to a maximum of five more years. Researchers asked patients to pick one of two future scenarios: either they would live whole 5 years, be in and out of the hospital 3 times in the last 2 months of life, and receive life support in an intensive care unit (ICU) for 3 weeks at the end of life with moderate pain and discomfort; or they would live 4 more years, be admitted to the hospital once in the last month of life, and then spend the last several weeks of life at home drifting in and out of awareness with mild pain and discomfort before dying at home.

Overall, 156 patients (86.7%) said they would trade a full year of time alive to avoid the scenario in which they were in the ICU for 3 weeks at the end of life and died on life support, researchers report in JAMA Internal Medicine.

"There is growing evidence that most adults with cancer want to die at home and have a natural death avoiding aggressive treatment like intubation at end-of-life," said Dr. Emily Johnston of the Institute for Cancer Outcomes and Survivorship at the University of Alabama in Birmingham.

"This study shows that many, but not all, people with other serious illnesses are willing to sacrifice some time alive to have less pain and suffering at end-of-life," Johnston, who wasn't involved in the study, said by email.

As the novel coronavirus pandemic continues to claim lives around the world, including many younger adults and otherwise healthy individuals who may not have given much thought to their wishes for end-of-life care, conversations about interventions and palliative care options are more crucial than ever, Johnston said.

"The corona virus pandemic highlights the uncertainty of everyone's health," Johnston said.

It is essential that everyone consider their end-of-life wishes and then talk to their loved ones and/or medical team about those wishes and complete the appropriate paperwork, be it living will or healthcare power of attorney, Johnston advised.

"Everyone should consider what they consider a life worth living and what trade-offs they would be willing to make," Johnston said. "They are hard conversations, but critically important."

Limitations of this study include the fact that the patients were recruited from a single center and were predominantly male, white, and married or partnered. These factors may limit generalizability.

Lead author Dr. Emily Rubin of Massachusetts General Hospital in Boston was unavailable to comment on the study.

While the hypothetical questions posed to patients in the study might not necessarily help people make actual treatment decisions in real time, the general guidance provided by responses to these questions might be a helpful framework for patients, families, and clinicians to discuss preferences for end-of-life care, said Dr. J. Randall Curtis, director of the Cambia Palliative Care Center of Excellence at UW Medicine in Seattle.

"The most important take home message is that it is important for patients with a chronic life-limiting or a terminal disease to talk with their families and their doctors about what is most important to them about their quality of life and whether they can imagine situations in which they would not want to be kept alive on life support machines," Curtis, who wasn't involved in the study, said by email.

SOURCE: JAMA Internal Medicine, online April 6, 2020.