Opportunity lost: End‐of‐life discussions in cancer patients who die in the hospital (original) (raw)
Related papers
Journal of Clinical Oncology, 2010
Purpose Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences. Methods This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians. Results Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 pa...
End-of-life discussions: Who's doing the talking?
Journal of Critical Care, 2018
To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions. Methods: Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chisquare tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?" Results: Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p b 0.001) was statistically significantly associated with discussing endof-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients. Conclusions: In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.
The American journal of hospice & palliative care, 2016
The association between physician-directed goals of care discussions (GOCDs) and the use of aggressive interventions in terminally ill patients has not been well characterized in the literature. We examined the associations between the timing of physician-directed GOCDs in terminally ill patients and the use of aggressive interventions, probability of dying in the inpatient setting, and intensive care unit (ICU) utilization. This retrospective cohort study included patients admitted to our urban community hospital in 2015 who had a terminal diagnosis on admission and either died on an inpatient unit or were discharged to hospice. The primary independent variable was the number of days from admission to GOCD, expressed as a proportion of the patient's length of stay (LOS). We used robust variance Poisson and zero-inflated negative binomial regression, as appropriate, to estimate the associations between goals of care timing and risk of having an intervention, risk of dying in the...
BMC Palliative Care, 2019
Background: End-of-life (EOL) conversations in hospital should serve to give patients the opportunity to consider future treatment options and help them clarify their values and wishes before it becomes relevant to make decisions about treatment. However, it is known that EOL conversations are not performed systematically in hospital. This may mean that patients and their relatives do not address EOL issues. There is a lack of knowledge about who is responsible for conducting these conversations, and when and under what circumstances they are conducted. The aim of this study was to explore the existing practices regarding EOL conversations in an acute care hospital setting. Methods: The design was Interpretive Description and the methods for the data collection included: 1. Participatory observational studies in a pulmonary medical and surgical ward (a total of 66 h); 2. Four focus group interviews with healthcare professionals (n = 14) from the wards. The analysis followed Spradley's ethnosemantic analysis. Results: The results revealed three cultural categories related to: 1. The physical and organizational setting; 2. The timing of EOL conversations and competencies and roles in addressing EOL issues and 3. Topics addressed in EOL conversations. The EOL conversations were part of daily clinical practice, but there was a lack of competencies, roles were unclear and the physical and organizational environment was not conducive to the conversations. The topics of the EOL conversations revolved around a "here-and-now" status of the patient's disease progression and decisions about the level of treatment. To a lesser extent, the conversations included the patient's and relatives' thoughts and wishes concerning EOL, which allowed long-term care planning. Conclusion: This study demonstrates that there are several barriers to talking about EOL in an acute care hospital setting, and future strategies must address an overall approach. In order to provide patients and their relatives with better opportunities to express their EOL wishes, there is a need for clearer roles and guidelines in an interdisciplinary approach to EOL conversations, alongside improved staff competencies and changes to the organizational and physical environment.
Journal of the American Medical Directors Association, 2018
Objective: Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionalseresidents and health care professionalsefamily EOL conversations and EOL care outcomes. Design: Systematic review with meta-analysis. Setting and Participants: Seven databases were searched in December 2017 to find studies that focused on health care professionalseresidents (without oncologic disease) and health care professionalsefamily EOL conversations and aimed to explore the impact of EOL conversations on resident's or family's EOL care outcomes. Measures: Random effects meta-analyses with subsequent quality sensitivity analysis and metaregression were performed to assess the effects of EOL conversations on the decision to limit or withdraw life-sustaining treatments. A funnel plot and Eagger test were used to assess publication bias. Results: 16 studies were included in the qualitative and 7 in the quantitative synthesis. Health care professionalsefamily EOL conversations were positively associated with the family's decision to limit or withdraw life-sustaining treatments (odds ratio ¼ 2.23, 95% confidence interval: 1.58-3.14). The overall effect of health care professionalsefamily EOL conversations on the family's decision to limit or withdraw life-sustaining treatments remained stable in the quality sensitivity analysis. In the metaregression, family members with a higher level of education were less influenced by EOL conversations with health care professionals when making decisions about limiting or withdrawing lifesustaining treatments. No publication bias was detected (P ¼ .4483). Conclusions/Implications: This systematic review shows that EOL conversations promote palliative care. Structured conversations aimed at exploring NH resident preferences about EOL treatment should become routine. NH administrators should offer health care professionals regular training on EOL conversations, and resident-centered care that involves residents and their families in a shared decisionmaking process at EOL needs to be promoted.
American Journal of Hospice and Palliative Medicine, 2016
Background: The association between physician-directed goals of care discussions (GOCDs) and the use of aggressive interventions in terminally ill patients has not been well characterized in the literature. We examined the associations between the timing of physician-directed GOCDs in terminally ill patients and the use of aggressive interventions, probability of dying in the inpatient setting, and intensive care unit (ICU) utilization. Methods: This retrospective cohort study included patients admitted to our urban community hospital in 2015 who had a terminal diagnosis on admission and either died on an inpatient unit or were discharged to hospice. The primary independent variable was the number of days from admission to GOCD, expressed as a proportion of the patient's length of stay (LOS). We used robust variance Poisson and zero-inflated negative binomial regression, as appropriate, to estimate the associations between goals of care timing and risk of having an intervention, risk of dying in the inpatient setting, odds of ICU admission, and ICU LOS. Results: A total of 197 cases were included. After adjusting for age, language, gender, insurance, dementia, and decision maker (patient versus surrogate decision maker), later GOCD was significantly associated with greater risk of having an aggressive intervention (risk ratio [RR] ¼ 1.04, 95% confidence interval [CI] ¼ 1.02-1.06), greater risk of death as an inpatient (RR ¼ 1.04, 95% CI ¼ 1.02-1.06), and greater odds of ICU admission (odds ratio ¼ 1.19, 95% CI ¼ 1.02-1.39). Conclusion: Later GOCDs were associated with greater risk of aggressive interventions and death as an inpatient and greater odds of ICU admission. Goals of care discussion should be done routinely and early during the hospitalization of terminally ill patients. Keywords advance care planning, goals of care, goals of care discussion, end-of-life care, terminally ill, intensive care units, length of stay, hospice care, quality