Early End-of-Life Discussions Affect Aggressiveness in Treating Incurable Cancers

Initiating discussions about end-of-life care with patients with incurable cancers early in their disease was associated with a decrease in late-stage aggressive cancer treatments such as chemotherapy or acute care, and with an increase in the use of hospice care at the end of life, according to the results of a prospective study.

“Previous work has suggested that end-of-life discussions affect the care that patients receive, but we did not know, prior to this study, whether having discussions earlier mattered,” said Jennifer W. Mack, MD, MPH, of the Dana-Farber Cancer Institute, who published the results of this study with colleagues in the Journal of Clinical Oncology.

Current recommendations issued by organizations such as the National Comprehensive Cancer Network and the National Consensus Project for Quality Palliative Care recommend that discussions about end-of-life care begin early in the course of disease for patients with incurable cancer. However, some studies have shown that these discussions are not occurring as early as they should.

Mack and colleagues studied 1,231 patients from the Cancer Care Outcomes Research and Surveillance Consortium who had stage IV lung or colorectal cancer. All patients died during the course of the study but survived at least 1 month. The researchers noted the timing, providers, and location of end-of-life discussions and sought to examine if there was any relationship to aggressiveness of care defined as treatments such as chemotherapy in the last 14 days of life or acute care.

Of the studied patients, 16% received chemotherapy in the last 14 days of life, 6% received intensive-care unit care in the last 30 days of life, and 40% received acute hospital-based care in the last 30 days of life. Almost half of all patients studied received at least one of the aggressive treatment types.

Data indicated that 794 patients had information about the timing, providers, and location of the end-of-life discussion. Thirty-nine percent of these discussions took place within 30 days of the end of life; 40% of the discussions included an oncologist, and 63% were conducted while the patient was an inpatient. In addition, patients who were hospitalized at the time of the end-of-life discussion were more likely to receive acute care and intensive care unit-based care in the last month of life, the study indicated.

“We found that patients who had earlier discussions about end-of-life care planning, especially before the last month of life, tended to receive less aggressive end-of-life care, including less chemotherapy at the end of life, less acute hospital-based care, and more and earlier use of hospice,” Mack said.

This study suggests that physicians should initiate discussions about end-of-life care planning early, according to Mack.

“For patients with metastatic lung or colorectal cancer, whose cancer is known to be incurable at diagnosis, physicians should strongly consider making these discussions a standard part of early discussions about cancer care, and not waiting until the patient is acutely ill and near death,” she said. “Doing so may give patients that best possible chance of making their wishes for end-of-life care known, and making decisions that maximize quality of life.”