End-of-Life Discussions Are Associated With Longer Survival and Higher Quality of Life
A review of advance care planning and end-of-life communication practices among physicians by the American College of Physicians has found that implementing early discussions about goals of care with seriously ill patients results in better quality of life, reduced use of life-sustaining treatments near death, earlier hospice referrals, and care that is more consistent with patient preferences. In addition, the review found that patients who received early palliative care survived 25% longer. Engaging in discussions about end-of-life care is also associated with improved bereavement outcomes for family members and reduced medical costs. The article by Bernacki et al is published in JAMA Internal Medicine.
Study Methodology
Members of the American College of Physicians (ACP) High Value Care Task Force conducted a review of advance care planning and end-of-life communication practices. Both observational and intervention studies were included, as well as indirect evidence from high-quality studies of palliative care specialist interventions that address the impact of communication about serious illness care planning on outcomes. The goal of the review of these studies was to provide clinicians with practical, evidence-based advice. The most common clinical conditions reviewed in this study include cancer, congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease and/or end-stage renal disease.
Study Findings
The study authors found that absent, delayed, or inadequate communication about end-of-life preferences is associated with poor quality of life and anxiety, family distress, prolongation of the dying process, undesired hospitalizations, patient mistrust of the health-care system, physician burnout, and high costs. In a prospective study to assess coping of patients with cancer, investigators found that only 37% of 332 patients, on average 4 months before death, reported having discussed end-of-life issues with their physicians. When conversations were conducted, patients reported better quality of life, received less aggressive medical care near death, and were referred earlier to hospice.
In addition, these patients were more likely to know that they were terminally ill, were peaceful, and desired and received less-invasive care. Bereavement adjustment for families was also better.
Studies of advance care planning in general medical populations also showed positive results with patients receiving the intervention more likely to have their wishes known and followed.
In general, the study found no evidence suggesting that communication about goals of care and end-of-life issues resulted in increased levels of patient anxiety, depression, and/or hopelessness.
Recommendations for Clinicians
The study authors propose the following steps to develop a system for improving communication about serious illness care goals with their patients:
- Training clinicians to enhance competencies in conducting discussions
- Identifying patients at risk of dying
- Developing “triggers” to ensure discussions take place at the appropriate time. For example, all patients should have an initial conversation about serious illness care goals at the time of second-line chemotherapy.
- Using a checklist or conversation guide to support clinicians and ensure adherence to best practices
- Providing a structured documentation template for serious illness care goals in electronic health records
- Devising a system to measure performance
Rachelle E. Bernacki, MD, MS, of Dana-Farber Cancer Institute, is the corresponding author for the JAMA Internal Medicine article.
The study was supported by the American College of Physicians, Partners Healthcare, and the Charina Foundatio. The study article authors reported no conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
