Earlier end of life care discussions resulted in lower use of acute care in the last 30 days of life
Results from a large population- and health systems-based prospective study show scientific evidence that timing of end of life (EOL) care discussions affects decisions about EOL care. Earlier discussions about EOL care preferences are strongly associated with less aggressive care in the last days of life and increased use of hospice care for patients with advanced cancer.
The findings, published in the Journal of Clinical Oncology, suggest that beginning EOL care discussions before the last month of life provides the patients with time to process the information with family members and create plans based on discussion information.
Current national guidelines state that discussions about EOL care should be initiated “during periods of relative medical stability rather than acute deterioration, and with physicians that know the patient well.”
“Research has shown that choosing less aggressive care at the end of life offers important benefits for both patients and their caregivers. 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,” said lead author Jennifer W. Mack, MD, MPH, a pediatric hematologist/oncologist at Dana-Farber/Children’ Hospital Cancer Center. “This is also important because studies have shown that aggressive care is associated with a higher risk of depression among bereaved caregivers of cancer patients.”
For the study, investigators identified 1231 patients (or surrogates of patients who were deceased or too ill to participate) with end-stage lung or colorectal cancer who, according to their medical records, discussed hospice and resuscitation. Researchers found that, on average, EOL discussions began 33 days prior to death, and 39% of those discussions occurred within the last 30 days.
At least one form of aggressive care was administered to almost half of all study participants. These included: chemotherapy in the last 14 days of life, intensive care unit (ICU) care in the last 30 days of life, and acute, hospital-based care in the last 30 days of life. Yet, when compared to cases in which EOL discussions took place within the last 30 days of life, cases with earlier EOL discussions were associated with less frequent use of aggressive care (34%-45% vs 65%) and increased use of hospice care (68%-77% vs 49%).
Furthermore, although the EOL discussions were documented in patient medical records, 17% of patients or surrogates involved in the study did not remember them, suggesting the content of the discussion may not have been fully comprehended.
Additional research is needed regarding how the content of EOL care discussions affects patients’ comprehension of the information and subsequent decisions made, the scientists said. Moreover, the study emphasizes a need for professional and patient groups to include advanced cancer care planning in physician education and training programs.