Perhaps nosingle issue ismore challengingfor health careproviders thanhow to talkwith patientsabout a poorprognosis,or limitedtreatmentoptions.
This month we want to take a look at thechallenges associated with communicatingbad news to a patient or caregiver.
None of us want to deprive a patient ofhope, so we often postpone or totally avoidthe hard conversation(s). Yet, there is agrowing body of evidence that patients whoparticipate in end of life discussions withtheir physicians are no more psychologicallydistressed than patients who have not hadthose discussions. Surprisingly, according toat least one recent report of a study fundedby the National Cancer Institute and theNational Institute of Mental Health, end oflife discussions were actually associated withpositive effects. See J. Clinical Oncology; May20, 2008 Supplement; 26 (15); 2008 ASCOAnnual Meeting; Abstract 6505.
The study, “Medical Care and EmotionalDistress Associated with Advanced CancerPatients,’ is reported in the Journal of ClinicalOncology. The study is part of an ongoing,prospective, longitudinal, multi–institutionalstudy, “Coping with Cancer.” The principalinvestigators, presenting the results of theirwork at the American Society of ClinicalOncology annual meeting last June, reportedthat end of life discussions, “may result inincreased patient understanding of illnessseverity, fewer invasive procedures, and lowerrates of ICU admissions at the end of life.”
There are several note worthy findings inthis study.
• Less than one third of patients reporteddiscussing end of life care with theirphysicians.
• Patients who did have end of life discussionswere not more likely to meet criteriafor depression or to report feeling “nervousor worried” than those who did nothave such discussions.
•Patients who reported having end of lifediscussions were:
• More likely to acknowledge being terminally ill.
• More likely to value comfort care over lifeextension.
• More likely to complete do–not– resuscitateorder.
Among the 323 patients enrolled in the studywho died, those who reported discussionsabout end of life care were more than twice aslikely to enter a hospice program. They werealso less likely than those who did not discussend of life care to be admitted to and ICU or toundergo ventilation.
Also of interest is the potential cost savingsassociated with having meaningful end oflife discussions. Related findings from theCoping with Cancer study show a 30 percentreduction in health care costs in the last weekof life. The authors report that “if extrapolatedto the national level, based on the number ofcancer deaths per year, these
data suggest a difference in end of life careexpenditures of $304,539,932.00 betweenindividuals who had end of life discussionsand those who did not.” Keeping in mind thatcancer deaths account for less than 50 percentof hospice patients, these potential savingsbecome even more significant.
In a recently published paper in the Annalsof Internal Medicine, “ “I’m not ready forHospice”: Strategies for Timely and EffectiveHospice Discussions”, the authors suggestthat the biggest communication barrier isthat physicians are unsure of how to talk withpatients clearly and directly about their poorprognosis and limited treatment optionswithout depriving them of hope. The articlesuggests a structured strategy for discussinghospice and is worthwhile reading foranyone trying to improve the timeliness andeffectiveness of these difficult conversations.See Ann Intern Med. 2007;146:443–449
Hospice is and should be an invaluableand indispensable partner with the physicianin formulating and instituting end oflife discussions. A patient, armed with acompassionate, complete and frank disclosureof their prognosis and treatment options,along with a full understanding of the benefitsafforded by hospice, will be better prepared tomake the hard decisions they are faced with,be afforded more time to make preparationswith their family and friends for their death,and ultimately maximize the quality of theirlife.
The author is grateful to Quality of LifeMatters, a publication providing end of lifecare news and clinical findings for physicians,for allowing the reprint of limited portions ofits publication.
