Oct. 7, 2008 - Terminally ill patients who had
end-of-life discussions with physicians had a better quality of life
near death, compared to patients who did not have these discussions,
according to a study in the October 8 issue of Journal of the American
Medical Association. These patients also received less aggressive
medical care in their final week of life and were not more likely to
experience emotional distress.
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,” according to the JAMA report.
This was the first research to examine 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.
Alexi A. Wright, M.D., of the Dana-Farber Cancer
Institute, Boston, and colleagues examined this associations between
end-of-life discussions with physicians and the medical care that
terminally ill patients receive near death.
The study included patients with advanced cancer
and their informal caregivers (332 pairs of people). 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
(37.0 percent) 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 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), and
● 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 were associated with better patient quality of life, while
more aggressive medical care was associated with worse patient quality
of life.
Patients who reported engaging in these
conversations were significantly more likely to accept that their
illness was terminal, prefer medical treatment focused on relieving pain
and discomfort over life-extending therapies, and have complete a
do-not-resuscitate order.
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.
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.
"Our results suggest that end-of-life discussions
may have cascading benefits for patients and their caregivers. Despite
physicians’ concerns that patients may experience psychological harm due
to end-of-life discussions, we found no evidence that they were
significantly associated with increased emotional distress or
psychiatric disorders. Instead, the worst outcomes were seen in patients
who did not report having these conversations." the authors write.
"Given the adverse
outcomes associated with not having end-of-life discussions, there
appears to be a need to increase the frequency of these conversations.
By acknowledging that death is near, patients, caregivers, and
physicians can focus on clarifying patients’ priorities and improving
pain and symptom management."
Nursing Home Abuse, Medical Malpractice? Contact a lawyer.
click here
Keep up with the latest news for senior citizens, baby
boomers
