Discussing end-of-life issues with patients

Many people believe it “increases the patients’ emotional distress.”

To the contrary, researchers from the Dana-Farber Cancer Institute in Boston report, “such conversations can actually lead to improved quality of life — both for patients and their loved ones.”

First, the details.

• 332 pairs of patients with advanced cancer and their informal caregivers participated.
• Patients were followed from enrollment to death — about 4 months later.
• Bereaved caregivers were assessed about 6.5 months later.
• Patients’ mental health and caregivers’ bereavement adjustment were measured.
• The need for aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life were also reported.

And, the results.

• 37% of patients had end-of-life discussions.
• These discussions were not associated with higher rates of major depressive disorder or more worry.
• End-of-life discussions were associated with lower rates of ventilation (2% vs 11%), resuscitation (1% vs 7%), ICU admission (4% vs 12%), and earlier hospice enrollment (66% vs 45%).
• More aggressive medical care was significantly associated with worse patient quality of life and a higher risk of major depressive disorder in bereaved caregivers.
• Whereas longer hospice stays were associated with significantly better patient quality of life.
• Better patient quality of life was associated with significantly better caregiver quality of life.

The bottom line?
The authors concluded, “End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.”

However, caregivers must first determine if the patient desires this discussion. About 20% of patients don’t want to discuss death.

Dr. Holly Prigerson added, “To the best of our knowledge, [this study] is the first to show how care received affects the dying patient’s quality of life, and the first to show that a patient’s healthcare and quality of life near death significantly influence the adjustment of his or her bereaved survivors.”

11/30/08 17:26 JR