End-of-Life Care Discussions Among Patients With Advanced Cancer

Abstract

Background National guidelines recommend that physicians discuss end-of-life (EOL) care planning with cancer patients whose life expectancy is less than one year. Objective To evaluate the incidence of EOL discussions for patients with stage IV lung or colorectal cancer, and where, when, and with whom discussions take place. Design Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005. Setting Subjects lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama, or received care in one of five large health maintenance organizations or one of fifteen Veteran’s Health Administration sites. Patients 2155 patients with stage IV lung or colorectal cancer. Measurements EOL discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis. Results 73% of patients had EOL discussions identified by at least one source. Among patients who died during follow-up (N=1470), 87% had EOL discussions, versus 41% of patients who were alive at the end of follow-up (N=685). Among first EOL discussions documented in records (N=1081), 55% occurred in the hospital. Oncologists documented EOL discussions with only 27% of their patients. Among patients with documented EOL discussions who died during follow-up (N=959), discussions took place a median of 33 days before death. Limitations The depth and quality of EOL discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained. Conclusions Although most patients with stage IV lung or colorectal cancer have discussions with physicians about EOL care planning before death, many discussions occur during acute hospital care, with non-oncology providers, and late in the course of illness.

Family Involvement at the End-of-Life and Receipt of Quality Care

“…However, recent studies among mixed samples of veterans' and non-veterans' surrogates found no differences between the groups with regard to surrogates' roles, attitudes, or decision making. 31,34 Moreover, our national sample was composed of nearly 94% of all decedents who died at a VA facility during the study period and, thus, are representative of nonsuicide deaths. However, generalizability may be limited because we randomly excluded 2% of all deaths from our potential sample from only one large facility (San Juan VA in Puerto Rico) to manage workload.…”

Communicating About Prognosis: Ethical Responsibilities of Pediatricians and Parents

“…Previous research has found that communication tends to happen late; for example, among adult patients with metastatic cancer, conversations took place a median of 1 month before death. 43 In this study, although most patients did ultimately have discussions about end-of-life care with a physician before death, conversations tended to happen during acute inpatient hospitalizations near death, rather than close to diagnosis when the incurable nature of the cancer was first known or during times of relative medical stability when care decisions might be made more thoughtfully. Although most patients were able to talk about their wishes for end-of-life care before death, the timing mattered; patients who had earlier discussions were less likely to receive aggressive measures at the end of life and more likely to receive hospice care.…”

A Profile of Children with Complex Chronic Conditions at End of Life among Medicaid Beneficiaries: Implications for Health Care Reform

“…Indeed, the nature of their impairments and the presence of multiple CCCs may complicate the care children receive at EOL. Children and their families may encounter communication issues with clinicians about medical decisions and care goals, 19,20 poor care coordination, 21,22 and problems with prognosis. 23 Therefore, it may be challenging for children with complicated disease processes to receive quality EOL care.…”