Influence of patients' preferences and treatment site on cancer patients' end‐of‐life care

BACKGROUND:

Research suggests that patients' end‐of‐life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life‐extending therapy was associated with their EOL care.

METHODS:

Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life.

RESULTS:

Eighty‐three of 301 patients (27.6%) with advanced cancer wanted life‐extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life‐extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P ≤ .003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.16‐8.47) and less hospice services (OR, 0.52; 95% CI, 0.29‐0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life‐extending care were more likely to receive intensive care (adjusted OR [AOR], 2.91; 95% CI, 1.09‐7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26‐0.78). Treatment site was not identified as a significant predictor of EOL care.

CONCLUSIONS:

The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care. Cancer 2010. © 2010 American Cancer Society.     

Developing quality indicators for cancer end‐of‐life care

Quality indicators applicable to cancer end‐of‐life care exist, but have not been widely implemented. To advance this field, the authors worked with the Agency for Health Care Research and Quality and the National Cancer Institute to organize a national symposium to discuss key issues and future goals, based on a conceptual framework. Discussions focused on 8 key domains in end‐of‐life cancer care: pain; dyspnea; communication, care planning, and decision making; psychosocial care; communication about chemotherapy; depression; continuity, coordination, and care transitions; and spirituality and closure. Key themes included the need for clarity on definitions and key aspects of care within domains, the need to start implementing indicators in more developed domains, and the importance of high‐quality symptom assessment and documentation of key processes. Key areas for future work include development of more outcome indicators, methods to better incorporate indicators and patient‐reported outcomes into clinical processes of care, and coordination across domains and settings. Measuring the quality of end‐of‐life cancer care is essential to understanding how best to improve patient outcomes and care. Cancer 2009. © 2009 American Cancer Society.     

Physician factors associated with discussions about end‐of‐life care

BACKGROUND:

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.

METHODS:

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.

RESULTS:

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).

CONCLUSIONS:

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. Cancer 2010. © 2010 American Cancer Society.     

Intensity of integrated cancer palliative care plans and end‐of‐life acute medical hospitalisation among cancer patient in Northern Italy

A high hospital utilisation at the end of life (EOL) is an indicator of suboptimal quality of health care. We evaluated the impact of the intensity of different Integrated Cancer Palliative Care (ICPC) plans on EOL acute medical hospitalisation among cancer decedents. Decedents of cancer aged 18–84 years, who were residents in two Italian regions, were investigated through integrated administrative data. Outcomes considered were prolonged hospital stay for medical reasons, 2+ hospitalisations during the last month of life and hospital death. The ICPC plans instituted 90 to 31 days before death represented the main exposure of interest. Other variables considered were gender, age class at death, marital status, recent hospitalisation and primary cancer site. Among 6,698 patients included in ICPC plans, 44.3% presented at least one critical outcome indicator; among these, 76.5% died in hospital, 60.3% had a prolonged (12+ days) medical hospitalisation, 19.1% had 2+ hospitalisations at the EOL. These outcomes showed a strong dose–response effect with the intensity of the ICPC plans, which is already evident at levels of moderate intensity. A well‐ICPC approach can be very effective—beginning at low levels of intensity of care—in reducing the percentage of patients spending many days or dying in hospital.     

A population‐based study on the determinants of hospice utilization in the last year of life for Taiwanese cancer decedents, 2001–2006

Background: No population‐based studies conducted outside Western countries have identified determinants of hospice utilization for all ages and cancer groups. Objective: To evaluate associations between hospice utilization in the last year of life and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of healthcare resources at the hospital and regional levels in Taiwan. Methods: Retrospective cohort study using administrative data among 204, 850 Taiwanese cancer decedents, 2001–2006. Results: Rates of hospice utilization increased significantly (12.99–17.24%) over the study period. Hospice utilization was more likely for cancer patients who were female; over 65 years old; currently or formerly married; with ≤1 concurrent disease; diagnosed with breast cancer or cancer having a poorer prognosis; with distant metastasis, and longer illness duration (>2 months since diagnosis); receiving care in a teaching hospital or hospital with an inpatient‐hospice unit; and receiving care in a region with greater density of inpatient‐hospice beds. However, patients with hematological malignancies and esophageal cancer were less likely to use hospice care. Conclusions: Despite the 1.33 times increase in hospice utilization among cancer patients who died from 2001 to 2006, only one in six Taiwanese cancer decedents used hospice care in their last year of life. Our findings regarding determinants of hospice utilization should be used by healthcare professionals and policy makers to guide the development of policies and interventions that facilitate prognosis disclosure and EOL care discussions between physicians and patients, especially younger patients, to help the transition from curative to palliative care. Copyright © 2010 John Wiley & Sons, Ltd.