End-of-life discussions before the end of life

Partnership HealthPlan is a strong advocate for having end-of-life wishes discussed well before the end of life arrives. By doing so, it is more likely that patients’ own individual desires will be followed. It also can reduce the stress on family members, especially when different relatives have varying opinions on how much should be done.

The health care system’s shortcomings in advance care planning are well known and regularly documented. There are many reasons end-of-life discussions tend not to happen in a timely way. They are usually time and energy consuming. They often require more than a single discussion. They can be awkward and uncomfortable for patient, family, and the clinician. They are easy to put off.

A recent study in the Journal of Hospital Medicine adds to the body of literature on delays in end-of-life discussions and also points out the consequences. The study looked at cancer patients admitted to a single hospital in Michigan between 2004 and 2007 who died during the hospitalization. Of 145 patients, 80% had the ability to make their own decisions at the time of admission. For those patients who could make their own decisions when admitted, 40% lost the ability to make decisions during the hospitalization, and before their physicians initiated a discussion of their end-of-life wishes. The discussions did take place, but with surrogate decision makers.

Notably, intensive treatments and interventions were much more commonly used when end-of-life decisions were made by surrogates rather than by the patient. Mechanical ventilation rates were 56% when the surrogate decided, compared to 23% when the patient decided. For artificial nutrition, the rates were 46% vs. 25%. ICU care took place in 57% vs. 23%. Chemotherapy rates were 39% vs. 5%.

Each of these differences was highly statistically significant. The significance, of course, is not just statistical. The differences reflect the fact that when people know they are dying, they tend to opt for less invasive, less intensive treatment for themselves. Surrogate decision-makers often, for reasons that are fully understandable, opt for more care, even though it may be futile.

Discussing end-of-life options and wishes is ideally done well before the end of life approaches. For patients with advanced cancer requiring hospitalization for any reason, such discussions are especially important. As this study points out, if those discussions have not yet happened, they should be undertaken sooner rather than later. Seriously ill cancer patients can lose their decision-making capacity in a short period of time, and the opportunity to make their own decisions may be lost.

Richard Fleming, MD

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