Patients Can Handle End-of-Life Discussions

(October 8, 2008) - A new study says that when doctors have an end-of-life discussion with patients, they not only handle it well, it can help them. Terminally ill patients who had end-of-life discussions with physicians weren't any more likely to experience emotional distress, received less aggressive medical care in their final week of life and had a better quality of life near death. That was compared to patients who did not have these discussions. The study is in the Journal of the American Medical Association.

End-of-life discussions offer patients the opportunity to define their goals and expectations for the medical care that they want to receive near death. "But these discussions also mean confronting the limitations of medical treatments and the reality that life is finite, both of which may cause psychological distress. Studies suggest that physicians and patients are ambivalent about talking about death and often avoid these conversations. To date, however, research has not examined whether these discussions are associated with patients' psychological distress or medical care near death. Without this information physicians cannot weigh the risks and benefits of end-of-life discussions," the authors write.

The study included 332 patients with advanced cancer (Read about "Cancer: What It Is") and their informal caregivers. Patients were followed-up from enrollment to death, a median (midpoint) of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later. One hundred twenty-three of 332 patients reported having end-of-life discussions with their physicians.

The researchers found that such discussions were not associated with higher rates of major depressive disorder (Read about "Depressive Illnesses") or more worry, but these patients received significantly fewer aggressive medical interventions near death:

• lower rates of ventilation (1.6 percent vs. 11.0 percent)
• resuscitation (0.8 percent vs. 6.7 percent)
• ICU admission (4.1 percent vs. 12.4 percent)

Patients who had end-of-life discussions had earlier hospice enrollment (65.6 percent vs. 44.5 percent), and longer hospice stays (Read about "Hospice") were associated with better patient quality of life, while more aggressive medical care was associated with worse patient quality of life.

Caregivers of patients who received any aggressive care were at higher risk for developing a major depressive disorder, experiencing regret and feeling unprepared for the patient's death, compared with caregivers of patients who did not receive aggressive care. (Read about "Helping the Bereaved") They also had worse quality of life outcomes, including overall quality of life, self-reported health and increased role limitations. Better patient quality of life was associated with better caregiver quality of life at follow-up.