Terminally ill opt for less treatment when in communication with doctors
Posted on Tuesday, November 27th, 2012 at 1:43 pm by Life Matters Media
Cancer patients who talk with their physicians about how they want to die are less likely to opt for aggressive end of life treatments in the last two weeks of life, according to a new study published in the Journal of Clinical Oncology. Instead, these patients end life more comfortably at home or in hospice care, and as a result spend much less on hospital care.
“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said Dr. Jennifer Mack, lead author of “Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study.”
The researchers studied more than 1,200 patients with stage IV lung or colorectal cancer who survived at least one month from the time of diagnosis, but died during the 15-month study period. Using interviews of the patients and/or their caregivers and a comprehensive medical record review, the researchers determined if and when the patients had discussions with their doctors about end of life.
Researchers found that 88 percent had end of life discussions, but more than one-third of those took place less than a month before the patient died. Those patients who had end of life discussions documented in the medical record but did not recall them in the patient or surrogate interviews were more likely to have chemotherapy within the last 14 days of life, or acute intensive or hospital care within the last 30 days of life.
Patients who reported having the discussions with doctors were almost seven times more likely to end up in hospice than those who didn’t have those talks. Hospice focuses on comfort care and pain management for terminal patients, instead of treatment.
“A lot of patients don’t want (aggressive treatment), but they don’t recognize that they’re dying or that this is relevant for them,” said Dr. Camilla Zimmermann, head of the palliative care program at University Health Network in Toronto. She wasn’t involved in the study.
She told Reuters: “The earlier you discuss these things, the more options you have. If you wait too long, you end up having these discussions with someone you don’t know, that you just met, in an inpatient setting,” instead of with your primary doctor.
According to Mack, ”If we start these conversations early, then patients have some time to process this information, to think about what’s important to them (and) to talk with their families about that.”
In 2010, Medicare paid $55 billion for doctor and hospital bills during the last two months of patients’ lives- more than the budget for the Department of Homeland Security, according to CBS News. Twenty to 30 percent of those medical expenses may have had no meaningful impact on the patients’ health.
Reuters is reporting data from the Dartmouth Atlas of Health Care, which found that 32 percent of total Medicare spending goes to caring for sick patients in their last two years of life.
National guidelines recommend patient-physician talks begin soon after a terminal cancer diagnosis. Researchers found that physicians initiated end of life discussions an average 33 days before death.
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Unrealistic expectations among the terminally ill
Posted on Sunday, October 28th, 2012 at 3:03 pm by Life Matters Media
Terminally ill patients often have unrealistic expectations of their treatments, write Thomas J. Smith, M.D. and Dan L. Longo, M.D. in an editorial for the October 25 issue of The New England Journal of Medicine. The physicians are advising their peers on how to facilitate open discussions with their patients about palliative care options and death.
The medical oncologists begin their editorial with a statement about the foolishness of self-deception, which they describe as a valuable personal coping tool. “It allows us to aspire to significance, strive for new knowledge, and yearn to make a lasting contribution to the world despite the certainty of our inevitable end. Indeed, no arduous task would ever be undertaken if we were unable to exaggerate the benefits we expect from it and underestimate the difficulty of its accomplishment.”
To them, this ”planning fallacy” is a symptom of human nature. The need to hope, they write, leads to unnecessary and expensive care at end of life.
This “self-deception” is illustrated in a study also published in the Journal by Dana-Farber Cancer Institute’s Jane C. Weeks, M.D. and colleagues: “Patients’ expectations about effects of chemotherapy for advanced cancer.” Twelve hundred patients with metastatic lung cancer or colorectal cancer were asked whether they expected their treatment to cure them. According to the study, the majority of patients felt their treatment would do so.
“If patients actually have unrealistic expectations of a cure … administered with palliative intent, we have a serious problem of miscommunication that we need to address,” Smith and Longo write.
Four possibilities could have resulted in unrealistic hope for some of the 1200 patients, the authors assert: 1) the patients surveyed may not have been told that their disease was incurable, 2) they were not told effectively, 3) they chose not to believe the message ,or 4) they responded too optimistically to the questions asked.
They share some surprising facts. Two thirds of doctors tell patients during an initial visit that they have an incurable disease, and only about a third actually state the true prognosis. On top of that, about one third of patients refuse to admit that treatment will not cure them.
The authors offer suggestions for improving communication between patients and physicians about terminal diagnoses. They suggest that oncologists provide more personalized information to patients. “Nearly all patients want to know whether or not they can be cured, and the majority want to know their prognosis.”
One tactic is “ask, tell, ask,” a method asking patients what they want to know, telling them and then asking if they understand. This should be done in a series of conversations.
“This ‘best practices’ model has allowed one large provider to double patients’ length of participation in hospice programs,” they write. This is important because palliative care increases knowledge of the prognosis and helps make patients more comfortable by reducing stress and pain.
Better communication also helps to reduce total costs of care. The authors note that 25 percent of all Medicare funds are spent in the last year of life. Life Matters Media has previously reported that a quarter of Medicare recipients spend more than the total value of their assets on end of life care.
At a recent forum at Northwestern University’s Buehler Center on Aging, Health and Society, George D. Lundberg, M.D. said that palliative care is the right option for some 80 percent of patients who die of chronic progressive disease. However, most of these patients die in intensive care units, and often against their will.
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