Later End-of-Life Discussions May Mean More Aggressive Treatment11/13/12
TUESDAY, Nov. 13 (HealthDay News) -- Terminally ill people who
get early counseling about end-of-life care undergo less aggressive
medical treatment in their final days, a new study reports.
The findings suggest -- but don't prove -- that patients who
only discuss their wishes at the last minute end up undergoing more
lifesaving efforts such as chemotherapy and intensive care. Those
who discuss their wishes earlier are more likely to undergo the
alternative -- treatments like hospice care whose main purpose is
to reduce suffering, not to continue extending life as long as
The findings show the importance of talking about a patient's
wishes as soon as possible, said study author Dr. Jennifer Mack, an
assistant professor of pediatrics at Harvard Medical School. "By
having these discussions earlier, patients can understand what's
ahead and make decisions about what's good for them."
The last several decades have spawned intensive debate about
whether aggressive medical treatment at the end of life results in
unnecessary suffering. In the new study, said to be the first of
its kind, researchers sought to understand whether the timing of
discussions with patients about terminal illness made any
difference in their care as they died.
The researchers tracked 1,231 patients with terminal lung or
colorectal cancer who died over a 15-month period.
Of those who only discussed end-of-life care in the final month
of life, 65 percent received what the researchers considered to be
aggressive care in those last 30 days.
By contrast, consider the patients who discussed end-of-life
care more than three months before death: Only about a third of
them received aggressive treatment in their final 30 days.
Overall, the numbers suggest that delaying discussions of
end-of-life care leads to more aggressive treatment during a
patient's final days instead of treatment that's purely designed to
Does this mean that terminal patients who discuss their wishes
earlier are more likely to get the treatment they desire at the
ends of their lives?
"That would be an inference. Patients who understand a poor prognosis are more likely to choose less aggressive care at the end of life," Mack said. "Not every patient wants palliative and less aggressive care, but most who recognize that they're dying want that."
Dr. Kathleen Unroe, an assistant professor of medicine at the
Indiana University Center for Aging Research, said that "earlier
discussions give patients and their families time to think through
what their preferences and goals of care are, and gives them more
time to communicate these wishes to providers."
It's disturbing, however, that the study revealed that some
patients -- especially blacks and Hispanics -- didn't realize
they'd had discussions about end-of-life care, she said.
Dr. David Casarett, director of research and evaluation at the
University of Pennsylvania Hospice and Palliative Care, praised the
study, saying it "provides welcome evidence that end-of-life
discussions may be able to change the trajectory of serious illness
in positive ways."
"Having earlier discussions -- ideally throughout the course of an illness -- gives patients a chance to ask questions, understand likely future events and clarify their goals," Casarett said. "Many of those discussions will bring to light new information or preferences, making it clear that a patient wants treatment that is less aggressive that what is being planned. When that happens, there is a unique opportunity to reconsider goals, opening the door to a plan of less aggressive treatment."
The study appears in the Nov. 13 online issue of the
Journal of Clinical Oncology.
For more about
end-of-life issues, try the U.S. National Library of Medicine.
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