Article

Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment

Department of Medical Oncology and Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, 550 Shields Warren, 44 Binney St, Boston, MA 02115, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 11/2008; 300(14):1665-73. DOI: 10.1001/jama.300.14.1665
Source: PubMed

ABSTRACT

Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.
To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.
A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.
Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.
One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001).
End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

Download full-text

Full-text

Available from: Susan D Block
    • "Advances in the management of late-stage cancer are accompanied by a host of challenges for individuals, families, and society (Aronowitz, 2010). In particular , the use of aggressive cancer-directed therapies in persons with very advanced disease is associated with psychosocial, physical, and existential distress and poorer quality-of-life (Schroepfer, 2007; Temel et al., 2010; Tullis, 2010; Wright et al., 2008). Geriatric cancer patients are particularly susceptible to the toxic side-effects of chemotherapy (Balducci, 2006). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Disease-directed therapy near death is a growing trend among persons living with late-stage cancer. As a sociocultural phenomenon, cancer-directed therapy (e.g., chemotherapy) when given for very advanced disease is a process that offers questionable benefits and portends further suffering, but also suggests potential for growth and transcendence. Theories and concepts drawn from cultural anthropology, sociology, and existentialism illustrate how contextual factors contribute to the creation of a “liminal space”; the latter part of the cancer trajectory where living and dying can overlap. When applied to clinical practice, this theoretical framework gives the patient, family, and health care provider a way of “unmasking” a period of transition during terminal illness when aggressive disease-directed care continues to be provided. The liminal space may function as an existential plane; a gateway or threshold with inherent potential for psychospiritual development during the final stage of life.
    No preview · Article · Jun 2015 · OMEGA--Journal of Death and Dying
  • Source
    • "Such decision making requires individuals who are emotionally close to and invested in the life of the decisionally incapacitated adult palliative loved one or friend, to make ultimate decisions that are likely to have a direct influence upon the conditions under which that person will die (Anderson, Arnold, Angus, & Bryce, 2008; Loomis, 2009; Silveira et al., 2010). Grief research has revealed that decision making for end-of-life care is a stressful period, after which there may be consequent emotional impacts (McCarron & McCallion, 2007; Weissman, 2004; Wright et al., 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: This paper examined differences in familial/friend surrogate decision makers’ (N = 93) post-bereavement grief and guilt associated with decisions to either prioritize comfort or longevity in determining end-of-life care for decisionally incapacitated adult palliative loved ones. Results demonstrated that participants prioritizing the longevity of loved ones experienced significantly and meaningfully higher levels of grief, complicated grief, and trauma related guilt than those who prioritized comfort.
    Full-text · Article · May 2015 · Death Studies
  • Source
    • "The goals of palliative care, such as improving quality of life through comprehensive symptom management and patient and family support, are ideally applied throughout the trajectory of a serious illness (Strand et al., 2013). There is growing recognition that increased intensity of invasive interventions in late stages of illness does not necessarily prolong survival or reliably improve quality of life (Wright et al., 2008). Social workers play a critical role in all aspects of palliative care including family-centered decision making, identification and reduction of symptom distress, psychosocial and behavioral health needs, and coordinated care (Altilio & Otis-Green, 2011). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The Institute of Medicine (IOM) Report—Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs—provided recommendations for meeting the palliative care needs of our growing population of older Americans. The IOM report highlights the demand for social work leadership across all aspects of the health care delivery system. Social workers are core interdisciplinary members of the health care team and it is important for them to be well prepared for collaborative leadership roles across health care settings. The ExCEL in Social Work: Excellence in Cancer Education & Leadership education project was created as a direct response to the 200815. Institute of Medicine. (2008). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: National Academies Press.View all references IOM Report. This article highlights a sampling of palliative care projects initiated by outstanding oncology social work participants in the ExCEL program. These projects demonstrate the leadership of social workers in palliative care oncology.
    Full-text · Article · Oct 2014 · Journal of Social Work in End-of-Life & Palliative Care
Show more