Even With Advance Planning, Aggressive Cancer Treatment Endures

While having an advance plan for end-of-life decisions has increased in cancer patients, aggressive treatments near the end of life continue to occur, according to a study published in JAMA Oncology.

Reviewing survey data from the Health and Retirement Study (HRS), a national longitudinal survey of 1,985 individuals age 50 years and older, Amol K. Narang, MD, resident in the department of radiation oncology at the Johns Hopkins Hospital in Baltimore, and colleagues found a 22% increase in cancer patients who designated durable power-of-attorney privileges to a loved one. Despite this planning, there was no impact on the rates of aggressive medical care in the patients’ last weeks of life.

All patients in the HRS died between 2000 and 2012. The study included interviews with surrogates following survey participants’ deaths.

According to the surrogates’ interviews, patients who received “all care possible” at the end of life increased from 7% in 2000 to 58% in 2012 (P = .004). Almost 40% of the surrogates noted that their loved ones did not discuss end-of-life care preferences with them. Hispanics and African Americans were more likely to have aggressive medical care at the end of life.

Eighty-one percent of survey participants engaged in at least one form of advance care planning, including 48% who had a living will, 58% who had designated a power of attorney, and 62% who had end-of-life discussions with family members. Designation of power of attorney increased from 52% in 2000 to 74% in 2012.

These results are consistent with other studies published in the last decade that showed increasingly aggressive cancer care near the time of death, even though there is evidence that suggests that aggressive end-of-life therapy is not associated with better outcomes or quality of life.

Patients who created living wills or had end-of-life discussions with family members were two times more likely to limit or withhold specific therapies at the end of life. Granting a power of attorney decreased the probability of terminally ill patients dying in a hospital setting rather than a hospice or their home.

“Although more cancer patients are assigning power-of-attorney privileges to someone they know and trust to make their medical decisions when they can’t, this practice may be the least helpful among advance care planning tactics because it may be least associated with treatment intensity at the end of life,” said Narang in a statement.

The survey information used for this study was subjective and patients’ answers on the survey could have been biased or inaccurate since they had to rely on their memory of events.

Still, the results suggest a need for better ways for clinicians to discuss end-of-life preferences with patients and their loved ones, said Narang. “We hope our findings renew efforts to encourage physicians and the public to have these critical end-of-life discussions,” he added.