Physician Factors Associated With Discussions About End-of-Life Care

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Cancer (Impact Factor: 4.9). 02/2010; 116(4):998-1006. DOI: 10.1002/cncr.24761
Source: PubMed

ABSTRACT Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end-of-life issues.
A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions.
Among 4074 respondents, 65% would discuss prognosis "now" (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death "now" (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis "now" (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death "now" (all P < .001).
Most physicians report they would not discuss end-of-life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life.

1 Follower
  • [Show abstract] [Hide abstract]
    ABSTRACT: Sympathetic and frank communication about the terminal nature of advanced cancer is important to improve patients' prognostic understanding and, thereby, to allow for adjustment of treatment intensity to realistic goals; however, decisions against aggressive treatments are often made only when death is imminent. This qualitative study explores the factors that hinder such communication and reconstructs how physicians and nurses in oncology perceive their roles in preparing patients for end-of-life (EOL) decisions.
    The Oncologist 10/2014; 20(1). DOI:10.1634/theoncologist.2014-0031 · 4.54 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: Palliative care has a positive effect on many clinical outcomes, yet most referrals to palliative care have occurred late. End-of-life (EOL) cancer care has become increasingly aggressive. There have been no studies investigating the association between early palliative care referrals and aggressive EOL care in Japan. Objective: This study was designed to explore the association between early palliative care referrals, inpatient hospice utilization, and aggressiveness of EOL care by investigating cancer decedents. Design: A retrospective cohort study in a cancer-designated hospital in Japan. Setting/Subjects: This study examined 266 consecutive cancer decedents. Inclusion criteria were adults and patients who died from cancer or causes related to cancer. Patients who died from causes unrelated to cancer were excluded. A total of 265 patients met the criteria. Measurements: We explored the association between early referrals (>3 months before death) and inpatient hospice utilization and the relationship between the timing of referrals and aggressive EOL care measured by a composite score adapted from Earle and colleagues. Results: Patients were divided into an early referral group (n=54) and a control group (n=211). The rate of inpatient hospice utilization was significantly higher in the early referral group (74% versus 47%, adjusted p<0.001). While each of six indicators of aggressiveness of EOL care did not differ significantly, the composite score was significantly lower in the early referral group (1.91±0.59 versus 2.14±0.78, adjusted p<0.001). Conclusions: Early palliative referrals were associated with more inpatient hospice utilization and less aggressive EOL care.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: Despite American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommending that oncologists discuss advance care planning (ACP) with patients with stage IV cancer early in treatment, in standard practice ACP remains a late step of a terminal illness. ACP preserves comfort and dignity at the end of life, ensuring patients receive the care that they desire. Methods and Materials: A feasibility study in patients with stage IV cancer was developed to test whether incorporating ACP immediately after a stage IV cancer diagnosis is feasible. Inclusion criteria were consecutive new gastrointestinal and thoracic oncology patients treated by one of two oncologists. The project included creation of new workflow; development of an ACP patient education guidebook; training seminars for oncology staff; and enhancements to the electronic health record (EHR) to improve ACP documentation. Results: The oncologists recorded 33 of 48 (69%) advance directive notes (ADNs) and 22 of 48 (46%) code status orders (CSOs) in the EHR of patients newly diagnosed with stage IV cancer by following ACP protocol during the 6-month trial period. Twenty-one of 33 ADNs were entered within 7 days of first consultation. The median time to ADN placement was 1 day after consultation. Twenty-two of 33 patients with ADNs had CSOs placed, of which 16 were do-not-resuscitate (DNR) and 6 were full code. One year prior to the feasibility study, only 1 of 75 deceased patients of the two oncologists had outpatient ADNs and CSOs. Conclusions: Outpatient ACP is feasible early in the care of patients with stage IV cancer through systematic improvement in workflow and motivated providers. Education and infrastructure were pivotal to routine development of advance care plans.
    Journal of Palliative Medicine 10/2014; 17(11). DOI:10.1089/jpm.2014.0085 · 2.06 Impact Factor