End of life cancer care
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By Wendy Wolfson

Timing Is Everything

Doctors often hesitate to make care plans with terminally ill patients

By Wendy Wolfson

Most people would expect that doctors who treat cancer patients would know when to talk to terminally ill patients about their prognosis and options for end-of-life care. But a new study suggests this may not be the case.

The study, published in the January issue of Cancer, asked more than 4,000 physicians what they would tell patients who didn’t yet feel ill, but who had only four to six months to live. Almost two-thirds of doctors surveyed said they would willingly tell patients their prognosis at that point, but only 44 percent said they would discuss do-not-resuscitate orders. Only 26 percent said they would immediately discuss hospice care, and only 21 percent said they would immediately ask patients whether they preferred to die in the hospital or at home.

“Doctors are trained to cure and to treat people,” says the study’s lead researcher, Nancy Keating, an epidemiologist at Harvard Medical School in Boston. However, doctors also must focus on helping patients understand when their disease is not curable, rather than simply offering additional rounds of chemotherapy when the drugs no longer work. “Doctors probably are delaying these conversations longer than they should,” she says.

When doctors don’t tackle the issue head-on, they may be compromising patient care. Alexi Wright, an oncologist at the Dana-Farber Cancer Institute in Boston, who also studies end-of-life care, says her research shows “that patients who had these conversations at least four months before they died were more likely to receive care that improved their quality of life at the end of life.”

This finding is bolstered by other studies which show that patients do not become significantly more depressed or anxious when end-of-life discussions occur months prior to death. Rather, these conversations help patients relate better to the terminal nature of their illness, says palliative care researcher Holly Prigerson, the director of the Center for Psycho-oncology and Palliative Care Research at Dana-Farber. They also help “shape their preferences and help surviving family members cope better.” Still, she says, “the challenge is knowing when a patient is ready to have these discussions.”

Because a patient’s physical and mental condition can deteriorate rapidly, Wright advocates that patients talk to doctors early on about the care they want at the end of their lives. And she advises doctors to not assume they know what a patient wants or needs. In her own practice, Wright says, she will “ask patients how much information they want, and what type of information they want, before discussing their prognosis or end-of-life wishes.”

It’s more than patients who benefit when physicians become better-trained and more comfortable in communicating with the terminally ill. “It may be that having these conversations improves not just a patient’s quality of life,” says Wright, “but also the caregivers’.”