David Brill
The decision to prolong life in advanced cancer patients presents an ethical, emotional, and financial challenge. Buying time can be costly, and a heavy legacy is often left for families and healthcare providers alike.
A new study suggests that physicians can play a major role in relieving this burden, simply by talking patients and families through their options and helping them to make plans in advance. Patients who had these end of life discussions received fewer aggressive interventions and had substantially lower medical costs, researchers found.
Economics aside, these discussions could also be in the patient’s best interests: the study found that high medical costs in the last week of life correlated to increased physical and psychological distress, and a worse quality of death. Moreover, survival was not significantly longer in patients who received aggressive therapies – raising questions as to whether the expense is justified.
Senior author Dr. Holly Prigerson said that patients ultimately have the right to choose, but that physicians can help to ensure that they make an informed decision.
“We’re not saying you should or you shouldn’t [prolong llfe], but you should at least realize what you’re buying with this more aggressive care. There is not improved quality of life,” she said.
“Whether they want to endure that pain is up to the patient to decide, but at least they should have the information to know that when they’re resuscitated, the likelihood that they’re going to survive an extra week really isn’t that much greater.”
Prigerson, director of the Center for Psychosocial Oncology and Palliative Care Research at the Dana-Farber Cancer Institute, Harvard Medical School, US, said that the study was born out of a belief among some oncologists that having end of life conversations would make patients “needlessly hopeless and depressed.” With data now showing that these discussions actually improve quality of life, she hopes that the study will bolster the confidence of physicians to address these “very difficult” subjects in future.
Singapore palliative care expert Dr. Cynthia Goh agreed that these conversations are important but stressed the need to approach them correctly. Physicians should listen to what patients and families want and guide them through their options, rather than pushing them towards a decision, she said.
“When talking about, for example, ‘do not resuscitate’ orders, the wrong way of doing things is to say: ‘do you want us to save your father or not?’” said Goh, director of the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School, Singapore.
“What they’re talking about in this paper is a different kind of end of life conversation, which is certainly not initiated in the hospital corridor. It’s not about ‘do you want this or do you want that’ – really it’s a conversation to say what is important for the patient. People go bankrupt for this kind of treatment, so having the chance to reflect on whether it is likely to fulfill their life goals is a very good thing.”
Prigerson and colleagues interviewed advanced cancer patients from several US institutions, and followed them up until death. Of 603 patients, 188 (31.2 percent) reported having had an end of life conversation with a physician at baseline. [Arch Intern Med 2009; 169(5):480-8]
The mean cost of care for these patients was US$1041 (35.7 percent) lower than in those who did not have such conversations (P=0.002). Medical costs did not correlate to survival time (P=0.70) but were associated with worse quality of death, as assessed by caregivers and family members (P=0.006).
Another recent study led by Prigerson found that cancer patients who used religion to cope with the advent of death were more likely to receive intensive life-prolonging care. [JAMA 2009; 301(11):1140-7]
The explanation remains unclear but the effect appears to be driven by be a subset of patients who are not lifelong believers but rather turn to religion as death approaches, she said. Their new-found beliefs could therefore be a proxy for psychological distress, which manifests in a desire to remain alive for longer.
Goh, who is also honorary secretary of the Asia Pacific Hospice Palliative Care Network and co-chair of the newly formed Worldwide Palliative Care Alliance, said that the findings were very interesting but may not be applicable to Asian populations since the study patients were all American Christians. She added, however, that religion is an important factor in end of life decisions, and said that physicians should take these beliefs into account on a patient-by-patient basis.
A new study suggests that physicians can play a major role in relieving this burden, simply by talking patients and families through their options and helping them to make plans in advance. Patients who had these end of life discussions received fewer aggressive interventions and had substantially lower medical costs, researchers found.
Economics aside, these discussions could also be in the patient’s best interests: the study found that high medical costs in the last week of life correlated to increased physical and psychological distress, and a worse quality of death. Moreover, survival was not significantly longer in patients who received aggressive therapies – raising questions as to whether the expense is justified.
Senior author Dr. Holly Prigerson said that patients ultimately have the right to choose, but that physicians can help to ensure that they make an informed decision.
“We’re not saying you should or you shouldn’t [prolong llfe], but you should at least realize what you’re buying with this more aggressive care. There is not improved quality of life,” she said.
“Whether they want to endure that pain is up to the patient to decide, but at least they should have the information to know that when they’re resuscitated, the likelihood that they’re going to survive an extra week really isn’t that much greater.”
Prigerson, director of the Center for Psychosocial Oncology and Palliative Care Research at the Dana-Farber Cancer Institute, Harvard Medical School, US, said that the study was born out of a belief among some oncologists that having end of life conversations would make patients “needlessly hopeless and depressed.” With data now showing that these discussions actually improve quality of life, she hopes that the study will bolster the confidence of physicians to address these “very difficult” subjects in future.
Singapore palliative care expert Dr. Cynthia Goh agreed that these conversations are important but stressed the need to approach them correctly. Physicians should listen to what patients and families want and guide them through their options, rather than pushing them towards a decision, she said.
“When talking about, for example, ‘do not resuscitate’ orders, the wrong way of doing things is to say: ‘do you want us to save your father or not?’” said Goh, director of the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School, Singapore.
“What they’re talking about in this paper is a different kind of end of life conversation, which is certainly not initiated in the hospital corridor. It’s not about ‘do you want this or do you want that’ – really it’s a conversation to say what is important for the patient. People go bankrupt for this kind of treatment, so having the chance to reflect on whether it is likely to fulfill their life goals is a very good thing.”
Prigerson and colleagues interviewed advanced cancer patients from several US institutions, and followed them up until death. Of 603 patients, 188 (31.2 percent) reported having had an end of life conversation with a physician at baseline. [Arch Intern Med 2009; 169(5):480-8]
The mean cost of care for these patients was US$1041 (35.7 percent) lower than in those who did not have such conversations (P=0.002). Medical costs did not correlate to survival time (P=0.70) but were associated with worse quality of death, as assessed by caregivers and family members (P=0.006).
Another recent study led by Prigerson found that cancer patients who used religion to cope with the advent of death were more likely to receive intensive life-prolonging care. [JAMA 2009; 301(11):1140-7]
The explanation remains unclear but the effect appears to be driven by be a subset of patients who are not lifelong believers but rather turn to religion as death approaches, she said. Their new-found beliefs could therefore be a proxy for psychological distress, which manifests in a desire to remain alive for longer.
Goh, who is also honorary secretary of the Asia Pacific Hospice Palliative Care Network and co-chair of the newly formed Worldwide Palliative Care Alliance, said that the findings were very interesting but may not be applicable to Asian populations since the study patients were all American Christians. She added, however, that religion is an important factor in end of life decisions, and said that physicians should take these beliefs into account on a patient-by-patient basis.
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