Terminally ill patients who had end-of-life discussions with physicians were not more likely to experience emotional distress, received less aggressive medical care in their final week of life and had a better quality of life near death, compared to patients who did not have these discussions, according to a study in the October 8 issue of JAMA.
End-of-life discussions offer patients the opportunity to define their goals and expectations for the medical care that they want to receive near death. "But these discussions also mean confronting the limitations of medical treatments and the reality that life is finite, both of which may cause psychological distress. Studies suggest that physicians and patients are ambivalent about talking about death and often avoid these conversations. To date, however, research has not examined whether these discussions are associated with patients' psychological distress or medical care near death. Without this information physicians cannot weigh the risks and benefits of end-of-life discussions," the authors write.
Alexi A. Wright, M.D., of the Dana-Farber Cancer Institute, Boston, and colleagues examined the associations between end-of-life discussions with physicians and the medical care that terminally ill patients receive near death. The study included patients with advanced cancer and their informal caregivers (n = 332 pairs). Patients were followed-up from enrollment to death, a median (midpoint) of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later. One hundred twenty-three of 332 (37.0 percent) patients reported having end-of-life discussions with their physicians.
The researchers found that such discussions were not associated with higher rates of major depressive disorder or more worry, but these patients received significantly fewer aggressive medical interventions near death: lower rates of ventilation (1.6 percent vs. 11.0 percent), resuscitation (0.8 percent vs. 6.7 percent), and ICU admission (4.1 percent vs. 12.4 percent). Patients who had end-of-life discussions had earlier hospice enrollment (65.6 percent vs. 44.5 percent), and longer hospice stays were associated with better patient quality of life, while more aggressive medical care was associated with worse patient quality of life.
Patients who reported engaging in these conversations were significantly more likely to accept that their illness was terminal, prefer medical treatment focused on relieving pain and discomfort over life-extending therapies, and have complete a do-not-resuscitate order.
Caregivers of patients who received any aggressive care were at higher risk for developing a major depressive disorder, experiencing regret and feeling unprepared for the patient's death, compared with caregivers of patients who did not receive aggressive care. They also had worse quality of life outcomes, including overall quality of life, self-reported health and increased role limitations. Better patient quality of life was associated with better caregiver quality of life at follow-up.
"Our results suggest that end-of-life discussions may have cascading benefits for patients and their caregivers. Despite physicians' concerns that patients may experience psychological harm due to end-of-life discussions, we found no evidence that they were significantly associated with increased emotional distress or psychiatric disorders. Instead, the worst outcomes were seen in patients who did not report having these conversations." the authors write.
"Given the adverse outcomes associated with not having end-of-life discussions, there appears to be a need to increase the frequency of these conversations. By acknowledging that death is near, patients, caregivers, and physicians can focus on clarifying patients' priorities and improving pain and symptom management."
(JAMA. 2008;300[14]:1665-1673. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
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