The Need for More Accurate Terminology in Discussing End-of-Life Options

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The letter by Dr Workman1 in response to the article “Health Care Costs in the Last Week of Life: Associations With End-of-Life Conversations,”2 as well as the reply from that article's authors,3 clearly points out the need for the use of more accurate terminology when discussing end-of-life care and interventions. I suggest that the dialogue include accurate value-neutral terminology when discussing the choice of a mentally competent, terminally ill patient to consume medication prescribed for the purpose of bringing about a peaceful death. This medical practice is increasingly referred to as aid in dying; this term has been adopted by the American Public Health Association, the American Medical Women's Association, and the American Medical Student Association. Those opposed to the practice intentionally use inaccurate, pejorative terms such as “assisted suicide” despite the widespread recognition that the choice of a dying patient for a peaceful death and “suicide” are starkly and fundamentally different. We applaud the discussion of the need to be sensitive in the use of terminology in the end-of-life arena and hope it extends to this medical practice as well.

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Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.
Zhang et al1(p480) introduce their study about communication at the end of life by observing that “Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly.” However, their data suggest that such “life-sustaining” treatments do not prolong life, although they clearly show that such suffering-inducing treatments result in a poorer quality of death.If treatment at the end of life is to be appropriate to the context, linguistic changes are required. So long as treatments are invariably conceived of and offered to such patient groups as “life sustaining,” physicians will have the very difficult task of convincing people that death is preferable to life. How many patients with terminal cancer would prefer suffering-inducing treatments over life-sustaining ones?