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Later End-of-Life Discussions May Mean More Aggressive Treatment
Date:11/13/2012

By Randy Dotinga
HealthDay Reporter

TUESDAY, Nov. 13 (HealthDay News) -- Terminally ill people who get early counseling about end-of-life care undergo less aggressive medical treatment in their final days, a new study reports.

The findings suggest -- but don't prove -- that patients who only discuss their wishes at the last minute end up undergoing more lifesaving efforts such as chemotherapy and intensive care. Those who discuss their wishes earlier are more likely to undergo the alternative -- treatments like hospice care whose main purpose is to reduce suffering, not to continue extending life as long as possible.

The findings show the importance of talking about a patient's wishes as soon as possible, said study author Dr. Jennifer Mack, an assistant professor of pediatrics at Harvard Medical School. "By having these discussions earlier, patients can understand what's ahead and make decisions about what's good for them."

The last several decades have spawned intensive debate about whether aggressive medical treatment at the end of life results in unnecessary suffering. In the new study, said to be the first of its kind, researchers sought to understand whether the timing of discussions with patients about terminal illness made any difference in their care as they died.

The researchers tracked 1,231 patients with terminal lung or colorectal cancer who died over a 15-month period.

Of those who only discussed end-of-life care in the final month of life, 65 percent received what the researchers considered to be aggressive care in those last 30 days.

By contrast, consider the patients who discussed end-of-life care more than three months before death: Only about a third of them received aggressive treatment in their final 30 days.

Overall, the numbers suggest that delaying discussions of end-of-life care leads to more aggressive treatment during a patient's final days instead of treatment that's purely designed to ease suffering.

Does this mean that terminal patients who discuss their wishes earlier are more likely to get the treatment they desire at the ends of their lives?

"That would be an inference. Patients who understand a poor prognosis are more likely to choose less aggressive care at the end of life," Mack said. "Not every patient wants palliative and less aggressive care, but most who recognize that they're dying want that."

Dr. Kathleen Unroe, an assistant professor of medicine at the Indiana University Center for Aging Research, said that "earlier discussions give patients and their families time to think through what their preferences and goals of care are, and gives them more time to communicate these wishes to providers."

It's disturbing, however, that the study revealed that some patients -- especially blacks and Hispanics -- didn't realize they'd had discussions about end-of-life care, she said.

Dr. David Casarett, director of research and evaluation at the University of Pennsylvania Hospice and Palliative Care, praised the study, saying it "provides welcome evidence that end-of-life discussions may be able to change the trajectory of serious illness in positive ways."

"Having earlier discussions -- ideally throughout the course of an illness -- gives patients a chance to ask questions, understand likely future events and clarify their goals," Casarett said. "Many of those discussions will bring to light new information or preferences, making it clear that a patient wants treatment that is less aggressive that what is being planned. When that happens, there is a unique opportunity to reconsider goals, opening the door to a plan of less aggressive treatment."

The study appears in the Nov. 13 online issue of the Journal of Clinical Oncology.

More information

For more about end-of-life issues, try the U.S. National Library of Medicine.

SOURCES: Jennifer Mack, M.D., MPH, assistant professor, pediatrics, Harvard Medical School, Boston; Kathleen Unroe, M.D., assistant professor, medicine, Indiana University Center for Aging Research, Indianapolis; David Casarett, M.D., director of research and evaluation at the University of Pennsylvania Hospice and Palliative Care, and associate professor, medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Nov. 13, 2012, Journal of Clinical Oncology, online


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