Three measures of aggressive end-of-life care “were associated with relatively large differences in family member–reported quality ratings for end-of-life care and a lower likelihood that patients with advanced-stage cancer received care congruent with their preferences,” according to a study in The Journal of the American Medical Association. The three measures were admissions to an intensive care unit (ICU) within 30 days of death, not receiving hospice care or receiving 3 days or less of hospice services, and deaths occurring in the hospital. The study findings “suggest that efforts to increase earlier hospice enrollment and avoidance of ICU admissions and hospital deaths might improve the quality of end-of-life care, concluded Alexi A. Wright, MD, MPH, of the Dana-Farber Cancer Institute, Harvard Medical School, Boston, and colleagues.
The study was based on interviews with family members of 1,146 Medicare patients with advanced-stage lung or colorectal cancer who were enrolled in the multiregional Cancer Care Outcomes Research and Surveillance Consortium study and died by the end of 2011. The median age of the patients was 76 years, and 55.8% were male. Most of the patients had stage IV disease at diagnosis.
Factors in ‘Excellent Care’
Family members reported excellent end-of-life care for 51.3% of the patients; very good care for 27.8%; and good, fair, or poor care for 20.9%. Patients’ end-of-life wishes were followed a “great deal,” according to 81.1% of family members, but 18.9% reported that end-of-life care was “somewhat” or “not at all” consistent with patients’ wishes.
Family members were more likely to report excellent care for patients who received hospice care for longer than 3 days (58.8% or 352 of 599) than those who did not receive hospice care or received 3 or fewer days (43.1% or 236 of 547), with an adjusted difference of 16.5 percentage points (95% confidence interval [CI], 10.7–22.4 percentage points). “In contrast, family members of patients admitted to an ICU within 30 days of death reported excellent end-of-life care less often (45.0% [68 of 151]) than those who were not admitted to an ICU within 30 days of death (52.3% [520 of 995]; adjusted difference, −9.4 percentage points [95% CI, −18.2 to −0.6 percentage points]),” the researchers found. “Similarly, family members of patients who died in the hospital reported excellent end-of-life care less often (42.2% [194 of 460]) than those who did not die in the hospital (57.4% [394 of 686]; adjusted difference, −17.0 percentage points [95% CI, −22.9 to −11.1 percentage points]).”
Only 56.7% of patients died in their preferred place of location. Family members were less likely to report that patients died in their preferred location if the patients did not receive hospice care or received 3 or fewer days (40.0% or 152 of 380) than if patients received hospice care for longer than 3 days (72.8% or 287 of 394), with an adjusted difference of −34.4 percentage points (95% CI, −41.7 to −27.0 percentage points).
“Improving end-of-life care offers an opportunity to improve the dying experience of patients with cancer, more effectively use resources, and potentially prolong survival,” the authors noted. They also cited “increasing evidence that physicians’ characteristics and beliefs are one of the strongest predictors of end-of-life care, suggesting that modifications to physicians’ practices may result in significant improvement.”