Talking about end-of-life wishes soon after a metastatic cancer diagnosis may lead to less aggressive, and potentially more comfortable, treatment in the last month of life, a recent analysis showed.
People who discuss their options earlier are also more likely to have hospice care than those who make end-of-life decisions after treatment stops working. Hospice care is specialized medical care to manage symptoms, control side effects and promote comfort toward the end of life.
Several practice guidelines recommend end-of-life care discussions take place early in the course of treatment for metastatic cancers so people can make decisions while they feel relatively well and have time to consider what they want. But past research shows doctors often wait until a person’s last 30 days of life to bring up the topic.
This study explored the relationship between timing of end-of-life care discussions and the kind of care a person received. It also considered the characteristics of people likely to recognize and understand those discussions.
The researchers analyzed data from 1,231 people with metastatic lung and colorectal cancer registered with the Cancer Care Outcomes Research and Surveillance Consortium, whose goal is to study quality of care, health outcomes and participant characteristics.
All participants lived at least one month after diagnosis and died by the time investigators stopped collecting medical records.
The researchers studied who was present for the end-of-life discussion, whether the discussion happened during hospitalization, when the discussion took place and whether the person had more or less aggressive care in the last month of life.
End of life discussions were:
- Reported by participants or by someone on their behalf as a conversation about resuscitation or hospice care
- Documented in participants’ medical records as a conversation about advanced care planning or where they wanted to be when they died
Aggressive care was defined as:
- Chemotherapy within the last two weeks of life
- Acute care within the last month of life (multiple visits to the emergency room or hospital, more than two weeks in the hospital, or death in the hospital)
- Treatment in the intensive care unit (ICU) within the last month of life
Overall, 88 percent of participants had end-of-life discussions. Nearly half had at least one form of aggressive treatment. Fifty-eight percent had hospice care, 15 percent of which started in the last seven days of life.
African-Americans and Latinos were less likely to report a discussion than their white peers. People who were not part of a health maintenance organization (HMO) were also less likely to report end-of-life discussions.
Of the 794 participants who reported when and where the discussion took place and who was part of the discussion:
- 39 percent had end-of-life discussion in the last month of life
- 40 percent had an oncologist present
- 63 percent took place while the person was staying in the hospital
The relationship between timing and quality of care showed:
- People who had discussions earlier were less likely to have aggressive care in the last month of life than those who had later discussions, and were also more likely to receive hospice care
- People who had discussions while staying in the hospital were more likely to have aggressive care in the last month of life than those who were not hospitalized at the time
What This Means For You
The researchers believe that most people living with metastatic disease want time to think about their desire to continue or stop treatment, explore hospice care options, and communicate with their families about their wishes. Having these discussions earlier in treatment may give you more clarity and a greater sense of control.
Your doctors may bring up end-of-life care, but if they don’t and you want to talk about it, it’s OK for you to ask for time to discuss options. LBBC also has a series of guides specifically for women living with metastatic breast cancer and information on lbbc.org that may help. We encourage you to call our Helpline if you want to talk to someone facing a similar diagnosis.
Mack, Jennifer W., Cronin, Angel, et al: Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study. J Clin Oncol (December 10, 2012) 30 (35): 4387-4395.