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Terminally ill cancer patients who have an early talk with their physician about care at the end-of-life are less likely to receive aggressive therapy – and more likely to enter hospice care – than patients who delay such discussions until the days and weeks before death, a new study by Dana-Farber Cancer Institute researchers suggests.
Having a conversation about end-of-life care several months before their condition begins to deteriorate may enable patients to think through their options more carefully than those who wait until the period immediately prior to their death, write the authors of the study, which is being published today in the Journal of Clinical Oncology. Patients in the study who discussed their end-of-life plans with their physician at least a month before death, tended to receive less aggressive care, less chemotherapy, and less acute care – choices that often bring a higher quality of life to a dying individual's final days.
"National guidelines recommend that discussions about end-of-life (EOL) care happen early for patients with incurable cancer," says the study's lead author, Jennifer Mack, MD, MPH, of Dana-Farber/Children's Hospital Cancer Center. "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."
The study involved 1,231 patients with highly advanced (stage IV) lung or colorectal cancer. All were participants in the Cancer Care Outcomes Research and Surveillance Consortium, a nationwide project sponsored by the National Cancer Institute on many aspects of cancer care. As part of the project, patients (or their surrogates) were asked whether they had discussed end-of-life care with their physician. Discussions about end-of-life care, and the timing of those discussions, also were recorded in patients' medical records.
The investigators found that 88 percent of the participating patients had end-of-life conversations, and 39 percent of those conversations took place in the last 30 days of life. In cases where EOL talks occurred more than 30 days before death, patients were less likely to receive aggressive care during their final days and more likely to receive hospice care.
"For patients in the final weeks of life, aggressive measures such as chemotherapy usually don't extend life, but they can lower the quality of time that remains," Mack comments. "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."
The study suggests that patients were more likely to choose quality-of-life care over aggressive care if they discussed the issue with their physician relatively soon after their diagnosis with incurable cancer. Postponing the conversation to the point where a patient's condition is rapidly deteriorating can place treatment decisions in the hands of the patient's family, rather than the patient them self, Mack notes.
She adds that aggressive care is not necessarily wrong for individuals at the end of life, but the decision of whether to pursue such care is still best made in the relative calm before the last few weeks of life.
The senior author of the study is Jane Weeks, MD, of Dana-Farber. Co-authors are Angel Cronin and Nathan Taback of Dana-Farber; Nancy Keating, MD, MPH, of Brigham and Women's Hospital; Haiden Huskamp, PhD, of Harvard Medical School; Jennifer Malin, MD, of the Los Angeles Veterans Administration Health Care System; and Craig Earle, MD, MSc, of the Ontario Institute for Cancer Research.
The study was funded by grants from the National Cancer Institute, the Department of Veterans Affairs, the American Cancer Society, and the National Palliative Care Research Center.