Posted online November 13, 2012 on www.jco.org.
A population- and health systems-based prospective study revealed that timing of end-of-life (EOL) care discussions strongly affects the intensity of care patients with advanced cancer receive near the end of life. Specifically, patients who had EOL care conversations with their doctors before the last 30 days of life were much more likely to receive hospice care and less likely to undergo “aggressive” medical care compared to those that had EOL conversations later. According to previous research, many patients who do not receive aggressive therapy at the end of life have a better quality of life in their final weeks.
Among the 1,231 patients with end-stage lung and colorectal cancer studied, EOL care discussions took place on average 33 days before death. For 4 out of 10 patients, the discussions occurred only in the last 30 days of life. Nearly half of all the patients that participated in the study received aggressive care, such as chemotherapy in the last 14 days of life, and acute hospital care or intensive care unit care in the last 30 days of life.
Timing of EOL discussions had not been explored in a longitudinal prospective clinical trial before. This study provides the first research-based evidence to support national guidelines that recommend that discussions about EOL care are initiated early for patients with advanced cancer.
What This Means for Patients
Discussing the end of life is difficult for patients and their families, as well as their doctors. Research shows that EOL care is discussed with nearly all patients but timing of those discussions varies. The results of this study demonstrate that starting discussion of EOL care has a strong impact on type of care patients receive in their final days. Having more time to process this information and make decisions is particularly important for patients with advanced cancer, who are emotionally overwhelmed and have a lot of concerns to deal with.
Another important benefit of early discussion of EOL care is introducing hospice care sooner, which has been linked to improved overall quality of life, and, in some cases, longer survival. Decreasing use of aggressive medical care near the end of life may also allow patients to spend their remaining time with family in the comfort of their home.
It is primarily the cancer doctor’s responsibility to lead EOL care discussions, but any member of the medical team, including general practitioner and emergency doctor, can initiate the discussion. Current guidelines state that this should ideally be a doctor that has an established relationship with the patient. Oncologists should create an advanced cancer care plan that aligns with a patient’s values and goals. Patients may also want to think about what is most important to them as they near the end of life − that should be the basis for making decisions about their care during that time.