Among family members of older patients who died of advanced-stage cancer, earlier hospice enrollment, avoidance of intensive care unit (ICU) admissions within 30 days of death, and death occurring outside the hospital were associated with perceptions of better end-of-life care, according to a study in the January 19 issue of JAMA.
Patients with advanced-stage cancer receive aggressive medical care at the end of life, despite increasing evidence that high-intensity treatments may not be associated with better patient quality of life, outcomes, or caregiver bereavement. Few studies have examined whether these aggressive end-of-life care measures reflect patients' preferences or bereaved family members' perceptions and expectations of the quality of end-of-life care.
Alexi A. Wright, M.D., M.P.H., of the Dana-Farber Cancer Institute, Harvard Medical School, Boston, and colleagues assessed the relationship between aggressive end-of-life care and family member-reported quality ratings of end-of-life care. The researchers used information obtained from interviews with family members of Medicare patients with advanced-stage lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance study who died by the end of 2011 (median, 144.5 days after death).
Of 1,146 patients with cancer (median age, 76 years; 56 percent male), bereaved family members reported excellent end-of-life care for 51 percent. Family members reported excellent end-of-life care more often for patients who received hospice care for longer than 3 days (59 percent [352/599]) than those who did not receive hospice care or received 3 or fewer days (43 percent [236/547]). In contrast, family members of patients admitted to an ICU within 30 days of death reported excellent end-of-life care less often (45 percent) than those who were not admitted to an ICU within 30 days of death (52 percent).
Similarly, family members of patients who died in the hospital reported excellent end-of-life care less often (42 percent) than those who did not die in the hospital (57 percent). Family members of patients who did not receive hospice care or received 3 or fewer days were less likely to report that patients died in their preferred location (40 percent) than those who received hospice care for longer than 3 days (73 percent).
The authors write that, as an example, implementation of multifaceted approaches (e.g., enhanced counseling of patients and families, early palliative care referrals, and an audit and feedback system to monitor physicians' use of aggressive end-of-life care) might result in more preference-sensitive care for patients and overall improved quality of end-of-life care.
"These findings are supportive of advance care planning consistent with the preferences of patients."
(doi:10.1001/jama.2015.18604; Available pre-embargo to the media at http:/media.jamanetwork.com)
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