Article

End-of-Life Discussions, Goal Attainment, and Distress at the End of Life: Predictors and Outcomes of Receipt of Care Consistent With Preferences

Dana-Farber Cancer Institute, Department of Pediatric Oncology, 44 Binney St-454, Boston, MA 02115, USA.
Journal of Clinical Oncology (Impact Factor: 17.88). 03/2010; 28(7):1203-8. DOI: 10.1200/JCO.2009.25.4672
Source: PubMed

ABSTRACT Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences.
This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians.
Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences.
Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.

Download full-text

Full-text

Available from: Susan D Block, Jun 17, 2015
0 Followers
 · 
83 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. Methods Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007–2011 were identified. Statistical analyses included Wilcoxon Mann–Whitney, Chi-square analysis, and multivariate analysis. Results 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30 days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p = < 0.001), with a median hospice stay of 18 days before death. Seventy-five percent had an in-hospital DNR and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12 days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378 days prior to death, respectively. Conclusions Many ovarian cancer patients underwent some form of aggressive medical care in the last 30 days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.
    Gynecologic Oncology 11/2014; 135(2). DOI:10.1016/j.ygyno.2014.08.039 · 3.69 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: There is evidence from some countries of a trend towards increasingly aggressive pharmacological treatment of patients with advanced, incurable cancer. To what extent should this be understood as a progressive development in which technological innovations address previously unmet needs, or is a significant amount of this expansion explained by futile or even harmful treatment? In this article it is argued that while some of this growth may be consistent with a progressive account of medicines consumption, part of the expansion is constituted by the inappropriate and overly aggressive use of drugs. Such use is often explained in terms of individual patient consumerism and/or factors to do with physician behaviour. Whilst acknowledging the role of physicians and patients’ expectations, this paper, drawing on empirical research conducted in the US, the EU and the UK, examines the extent to which upstream factors shape expectations and drive pharmaceuticalisation, and explores the value of this concept as an analytical tool.KeywordsUnited StatesUnited Kingdompharmaceuticalizationend-of-life cancer careexpectationsovertreatmentpatient preferencesclinical benefit
    Social Science & Medicine 12/2014; 131. DOI:10.1016/j.socscimed.2014.12.007 · 2.56 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: We examined the impact of palliative care (PC) on aggressiveness of end-of-life care for patients with advanced pancreatic cancer. Measures of aggressive care included chemotherapy within 14 days of death; and at least one intensive care unit (ICU) admission, more than one emergency department (ED) visit, and more than one hospitalization, all within 30 days of death. A retrospective population-based cohort study using administrative data was conducted in patients with advanced pancreatic cancer from 2005 to 2010 in Ontario, Canada. Multivariable logistic regression was performed with the above measures of aggressive care as the outcomes of interest and PC as the main exposure, adjusting for covariables. Secondary analyses examined intensity of PC as the main exposure defined in two ways: 1) absolute number of PC visits before the outcome of interest (0, 1, 2, 3+ visits) and 2) monthly rate of PC visits. The cohort included 5381 patients (median survival 75 days); 2816 (52.3%) had received a PC consultation. PC consultation was associated with decreased use of chemotherapy near death (odds ratio [OR] = 0.34, 95% confidence interval [CI] = 0.25 to 0.46); lower risk of ICU admission: OR = 0.12, 95% CI = 0.08 to 0.18; multiple ED visits: OR = 0.19, 95% CI = 0.16 to 0.23; multiple hospitalizations near death: OR = 0.24, 95% CI = 0.19 to 0.31). A per-unit increase in the monthly rate of PC visits was associated with lower odds of aggressive care for all four outcomes. PC consultation and a higher intensity of PC were associated with less aggressive care near death in patients with advanced pancreatic cancer. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    JNCI Journal of the National Cancer Institute 03/2015; 107(3). DOI:10.1093/jnci/dju424 · 15.16 Impact Factor