Opportunity lost: End‐of‐life discussions in cancer patients who die in the hospital

Abstract

BACKGROUND End-of-life discussions are associated with decreased use of life-sustaining treatments in patients dying of cancer in the outpatient setting, but little is known about discussions that take place during terminal hospitalizations. OBJECTIVES To determine the proportion of patients assessed by the clinical team to have decisional capacity on admission, how many of these patients participated or had a surrogate participate in a discussion about end-of-life care, and whether patient participation was associated with treatments received. DESIGN Retrospective review. SETTING Inpatient. PATIENTS Adult patients with advanced cancer who died in the hospital between January 1, 2004 and December 31, 2007. RESULTS Of the 145 inpatients meeting inclusion criteria, 115 patients (79%) were documented to have decisional capacity on admission. Among these patients, 46 (40%) were documented to lose decisional capacity prior to an end-of-life discussion and had the discussion held instead by a surrogate. Patients who had surrogate participation in the end-of-life discussions were more likely to receive mechanical ventilation (56.5% vs 23.2%, P < 0.01), artificial nutrition (45.7% vs 25.0%, P = 0.03), chemotherapy (39.1% vs 5.4%, P <0.01), and intensive care unit (ICU) treatment (56.5% vs 23.2%, P <0.01) compared to patients who participated in discussions. There was no difference between palliative treatments received. CONCLUSION The majority of patients with advanced cancer are considered to have decisional capacity at the time of their terminal hospitalization. Many lose decisional capacity before having an end-of-life discussion and have surrogate decision-makers participate in these discussions. These patients received more aggressive life-sustaining treatments prior to death and represent a missed opportunity to improve end-of-life care.

Communication in palliative care: talking about the end of life, before the end of life

“…In a recent Canadian study,19 physicians, residents and nurses reported that one of the top five barriers to ‘goals of care discussions’ was patients' lack of capacity. In line with this report, a recent review of the medical records of outpatients with cancer in the USA demonstrated that while 79% of patients were deemed to have capacity when admitted to hospital, 40% of these individuals lost capacity before an end-of-life care discussion could take place 20. Patients who lost capacity, and therefore had surrogate decision-makers, were significantly more likely to receive more aggressive life-sustaining treatments than those who took part in their own end-of-life care discussions.…”

The Advance Care Planning Readiness Scale: Development and Validation of a Measure of Willingness to Discuss and Acceptance of End-of-Life Care in Gynecologic Cancer Patients

“…Although EOLC conversations are challenging, it is imperative that providers encourage patients to engage in these difficult conversations before progressing to an advanced state of illness that renders them unable to make decisions for themselves. 17 The ACPRS is an 8-item scale that is valid and reliable. The scale provides a foundation for a tool that may be used to assess a gynecologic oncology patient's readiness to discuss EOLC topics and their acceptance of the need of EOLC support.…”

Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients

“…Unfortunately, many patients do not have early advance care planning discussions with their providers (9, 10). As a result, many patients experience aggressive medical care ranging from chemotherapeutic administration to multiple hospital admissions in the final days of life (7, 8).…”