End-of-life decisions

New study showing many terminal cancer patients receiving palliative chemotherapy die in the ICU highlights need for end-of-life discussions
Image: End-of-life decisions
Dr. Joel Policzer checks on Walter Norton in this Oct. 30, 2009 photo, in the hospice wing of an Oakland Park, Fla. hospital. Most of Policzer's patients have made no end-of-life decisions. A new study released this week found terminally ill cancer patients who received palliative chemotherapy were more likely to receive invasive procedures and late hospice referrals in their last few weeks of life. Many died in the ICU. J. Pat Carter / AP file

A new study published this week by the British Medical Journal highlights the importance of end-of-life discussions between doctors and their terminally ill cancer patients.

The study, which involved 386 terminal cancer patients, found that patients receiving palliative chemotherapy in the last few months of their life were much more likely to undergo invasive procedures like CPR, mechanical ventilation or both. And these patients were also more likely to die in an ICU as opposed to dying at home or where they wanted to die.

“Obviously, this reinforces concerns that we and others have had about continuing aggressive cancer treatment beyond a certain point when it’s not likely to prolong life,” said Dr. Gary Lyman, a breast cancer oncologist and co-director of the Hutchinson Institute for Cancer Outcomes Research at Fred Hutchinson Cancer Research Center. HICOR’s mission is to bridge research and clinical practice to improve cancer patients’ outcomes.

“These patients have reached a point where the likelihood of treatment offering anything beneficial is very low,” he said. “And yet the treatment comes with considerable side effects, which will sometimes land a patient in the hospital or the ICU. They’ll die there as opposed to the alternative: getting them home sooner so they can spend their last days or weeks with their family.”

Lyman said decisions to pursue aggressive chemotherapy at the end of life can be driven by doctors, by patients’ families or by the patients themselves. And despite hope and best intentions, late-term chemo can cause undue suffering.

'These are very important discussions to have'
“The doctors are doing everything they can to keep the patients alive and get them out of ICU, but they suffer,” he said. “If there’s a reasonable prospect to leave the ICU and go home, most people believe that suffering is worthwhile. But when the chances are almost zero, then you’re just inflicting pain with no gain. This is absolutely about death with dignity.”

According to the study, the use of palliative chemotherapy shortly before death was not only associated with invasive procedures and a higher likelihood to die in an ICU, but led to “worse quality of life for patients at the end of life, more distress in bereaved caregivers and higher costs.”

To avoid this, Lyman and the study’s authors highlight the importance of end-of-life discussions between oncologists and their terminally ill patients.

“I think it matters to ask patients where they want to die,” said lead author Dr. Alexi Wright of Harvard Medical School and Dana-Farber Cancer Institute. “It’s a difficult conversation to have, but one that’s necessary.” Wright said it was also crucial for oncologists to understand what patients want for their end-of-life care.

“We need to do our best to help them come to the right decision for their particular situation,” said Lyman. “These are very important discussions to have.” 

Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has also written extensively about health issues for nbcnews.com, TODAY.com, CNN.com, MSN.com, Columns, and several other publications. She also writes the breast cancer blog, doublewhammied.com.Reach her at dmapes@fredhutch.org.


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