Blog | Wednesday, February 8, 2012

QD: News Every Day--End-of-life discussions happen far too late

Most patients with stage IV lung or colorectal cancer discuss end-of-life care planning with physicians before death, but most often, the talks happen much too late.

Many end-of-life discussions occur during acute hospital care, with the median happening a month before death, researchers reported. National guidelines recommend that physicians discuss end-of-life care planning with patients with cancer whose life expectancy is less than one year.

To evaluate the incidence of end-of-life care discussions for 2,155 patients with stage IV lung or colorectal cancer, researchers designed a prospective cohort study of patients from the Cancer Outcomes Research and Surveillance Consortium (CanCORS), a group of patients diagnosed with lung or colorectal cancer from 2003 to 2005 from five large health maintenance organization insurance plans or 15 Veterans Health Administration sites in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama.

Results appeared in the Feb. 7 issue of Annals of Internal Medicine.

In the study, 73% of patients had end-of-life care discussions. Among the 1,470 patients who died during follow-up, 87% had end-of-life care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up.

For the 1,569 patients with end-of-life care discussions, topics included resuscitation (46%) and hospice care (82%). Other topics noted in medical records included palliative care (13%) and venues for dying other than hospice (3%). Of the 1,081 first end-of-life care discussions for which information was available, 55% occurred in the inpatient hospital setting.

Of the 806 first end-of-life care discussions documented in medical records for which provider type was known, participating providers included medical oncologists (49%), general medical physicians (36%), palliative care physicians (6%), other medical specialists (7%), radiation oncologists (4%), surgeons (3%), and other providers (0.5%).

Discussions with oncologists were divided evenly between inpatient and outpatient settings, but discussions with general medical physicians tended to take place in the inpatient setting (73%). Abstracted medical record data were available from visits with medical oncologists for 85% (1,823 of 2,155) of patients, with a median of 6 visits (interquartile range, 2 to 10). However, medical oncologists documented end-of-life care discussions with only 27% of their patients (493 of 1823).

"This finding suggests that acute medical deterioration, and not the diagnosis of incurable cancer, triggers physicians to talk about end-of-life care. The literature has also shown that physicians who have close long-term relationships with patients often wish to avoid end-of-life care discussions," the authors wrote. "Primary care physicians may also have important roles in end-of-life care decision making, but most discussions with general medicine physicians occurred in the inpatient setting, suggesting that these were hospital-based physicians and not those providing longitudinal primary care. Physicians involved in longitudinal care, however, may be best informed about the patient's prognosis and disease trajectory and best equipped to have meaningful discussions about the patient's values and goals."