Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment
By A. Wright, Baohui Zhang, A. Ray, J. Mack, E. Trice, T. Balboni, S. Mitchell, V. Jackson, S. Block, P. Maciejewski and 1 more. Journal of the American Medical Association (JAMA), 2008
2,680 citations recorded by the source corpus.
Context Talking about death can be difficult. Without evidence that end-of-life (EOL) discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern that EOL discussions may inflict psychological harm. Objective To determine whether EOL discussions with physicians are associated with fewer aggressive interventions. Design, Setting, Participants A United States multi-site, prospective, longitudinal cohort study of advanced cancer patients and their informal caregivers (n=332 dyads), September 2002-February 2008. Patients were followed from enrollment to death a median of 4.4 months later. Bereaved caregivers’ psychiatric illness and quality of life (QoL) was assessed a median 6.5 months later. Main Outcome Measures The primary outcome were aggressive medical care (e.g., ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients’ mental health and caregivers’ bereavement adjustment. Results 123 of 332 (37.0%) patients reported EOL discussions before baseline. EOL discussions were not associated with higher rates of Major Depressive Disorder (8.3% vs. 5.8; AOR 1.33, 95% CI 0.54-3.32), or more “worry” (6.5 vs. 7.0; p=0.19)). After propensity-score weighted adjustment, EOL discussions were associated with lower rates of ventilation (1.6% vs. 11.0%; AOR 0.26, 95% CI 0.08-0.83), resuscitation (0.8% vs. 6.7%; AOR 0.16, 95% CI 0.03-0.80), ICU admission (4.1 vs. 12.4%; AOR 0.35, 95% CI 0.14-0.90), and earlier hospice enrollment (65.6% vs. 44.5%; AOR 1.58, 95% CI 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient QoL (6.4 vs. 4.6; F=3.60, p=0.01) and higher risk for Major Depressive Disorder in bereaved caregivers (AOR 3.37, 95% CI 1.12-10.13), while longer hospice stays were associated with better patient QoL (5.6 vs. 6.9; F=3.70, p=0.01). Better patient QoL was associated with better caregiver QoL at follow-up (β=0.20; p=0.001). Conclusion EOL discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient QoL and worse bereavement adjustment.
Subfields: Clinical Psychology, Oncology, Public Health, Environmental and Occupational Health
View Paper: https://www.semanticscholar.org/paper/054b5c3f9ec4b74216c4bd543a8a60bba76ce7d1
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Citations in the corpus
- Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. (2017, background): “Patients with advanced cancer often fail to understand the intent of their cancer treatment and rarely engage in discussions about their preferences for care at the end of life (EOL).(10,11) Suchmisperceptions are associated withworse EOL-care outcomes.”
- Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. (2010, methodology): “Coping with Cancer was a prospective, longitudinal, multisite psychiatric epidemiologic study of terminally ill patients with cancer and their informal caregivers designed to determine the rates, causes, and consequences of psychiatric illness in terminally ill patients with cancer and their bereave”
- End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. (2010, methodology): “Subjects were recruited as part of the Coping with Cancer Study, a multiinstitutional longitudinal investigation of patients with advanced cancer and their primary (unpaid) caregivers.(4,18) This report describes 325 patients recruited between October 2002 and September 2007 whose self-reported trea”
- American Society of Clinical Oncology Clinical Practice Guideline update on chemotherapy for stage IV non-small-cell lung cancer. (2009, background): “In the largest prospective trials of communication, doctors only ever discussed prognosis with their patients with advanced cancer in 38% of cases(179) and only had a conversation about imminent death in 37% of cases.(180)”
- Dying in America: improving quality and honoring individual preferences near the end of life. (2015, background): “avoiding many physical and psychological stresses (Mack et al., 2010b; Wright et al., 2008).”