Article of the Month

Reviewed by: Maxine de la Cruz, MD

Associations Between End-of-Life Discussions, Patient Mental Health,
Medical Care Near Death, and Caregiver Bereavement Adjustment

Authors:  A. Wright, B Zhang, A Ray, J Mack, E Trice, T Balboni, S Mitchell, V Jackson, S Block, P Maciejewski, and H Prigerson

Journal: JAMA. 2008 (October 8); 300 (14): 1665-1673.

Summary

This is a prospective, longitudinal, cohort study consisting on 332 patients from different centers in the United States.  The aim of the study was to see whether end-of life discussions between physicians and terminally ill patients were associated with the medical care the patients received near death.   The investigators likewise sought to determine whether end-of-life discussions had an affect on the patient’s quality of life and psychosocial distress and the caregivers’ bereavement outcomes.

Upon study enrollment, information on patients’ and caregivers’ sociodemographic characteristics was collected. The patients were asked to answer several questionnaires on quality of life, functional status, and mental health.  Patients were followed weekly to within 2-3 weeks of death. The research staff reviewed the medical record documenting the types of medical care the patient received near death.  The caregivers were likewise interviewed after a median of 6.5 months following the patient’s death.  The questions focused on the patient’s final week of life and caregiver bereavement outcomes.

123 (37%) patients had end-of life discussions.  These patients had significantly poorer functional status (p<0.001), higher symptom burden (p= 0.02), and shorter survival times (p=0.002) compared to patients who did not have the discussion. 

Interestingly, patients who had end-of-life discussions with their physicians received fewer aggressive medical interventions near death such as mechanical ventilation (1.6% vs 11% p=0.02), cardiopulmonary resuscitation (0.8% vs 6.7% p=0.02), and ICU admission (4.1% vs 12.4% p=0.02).  Caregivers reported that patients who received aggressive medical interventions had a worse quality of life in the last week of life.  The inverse was true for those patients enrolled in hospice.  Caregivers of patients who received aggressive interventions were at higher risk of developing a major depressive disorder (OR = 3.37), and had worse quality of life outcomes. 

Several conclusions can be drawn from this study.  Having end-of-life discussions may be crucial for the patient’s understanding of his disease and the possible benefits of aggressive therapies which then may alter the future course of treatment.  Given the adverse outcomes associated with not having end-of-life discussions, engaging in these types of conversations with our patients is most advantageous.

Why I chose this Article?

There is very little information in the literature that can guide clinicians how to proceed with discussions regarding general goals of care, end-of-life issues, and delivering bad news to patients.  Part of the lack of enthusiasm in such discussions also arises from concern about its possible repercussions.  Prior studies have raised key issues that relate to the physician and patient side of the equation.  Concerns about taking away a patient’s hope, affects on over-all quality of life, fear of being perceived to have given up, and discomfort in emotional situations are examples of the reasons for a reluctance by some to discuss this important subject that ultimately impacts the care of our dying patients. I thought that this article presented very interesting but not completely surprising data.    However, the data should be interpreted with some caution and put in context.  Previous studies have shown that a huge proportion of cancer patients do not recall having end-of-life or prognostic discussions even if they had occurred.  Therefore the rates reported by patients may be an underestimate.  The content of the conversations were not available to investigators.  It is therefore difficult to fully assess whether those patients who report having these conversations were the patients most prepared to deal with the reality of their disease.  Overall, it is encouraging to see hard evidence of the benefits of informed disclosure.

 

Maxine de la Cruz, MD
Palliative Care Fellow
Department of Palliative Care and Rehabilitation Medicine
MD Anderson Cancer Center

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