Education Aids in Decision-Making to Prepare for End of Life

Being offered a brief, dedicated discussion of end-of-life decisions relatively early in the trajectory of advanced cancer led to an earlier placement of do-not-resuscitate orders and decreased the likelihood that patients died in a hospital, a new study showed.

“Our results suggest that patients do not become depressed or anxious in response to a relatively early discussion about the decisions that will face them at the end of their life,” said study author Louise Sharpe, PhD, of the University of Sydney, Australia. “Therefore, health care professionals should not fear that sensitive discussions about end-of-life decision-making would be harmful.”

Sharpe and colleagues conducted a study examining the effect of an intervention on end-of-life decision-making in patients with advanced cancer. The study was published in the Journal of Clinical Oncology.

“Although there continues to be some debate on the most appropriate time to discuss not-for-resuscitation orders and other end-of-life decisions, most physicians agree that it is important to place these early  in the trajectory of a terminal illness,” Sharpe told Cancer Network. “Data continues to suggest, however, that many patients do not have a not-for-resuscitation order placed until within days of their death-where they die in hospital-and that, in some cases, patients are given futile and invasive life-sustaining at the end of their life because the appropriate orders are not in place.”

In addition, Sharpe said that a high proportion of patients die in the hospital rather than at home or in a hospice facility despite the fact that most patients would prefer to avoid a hospital death.

In this study, 127 patients with metastatic cancer who were no longer being given curative treatment were enrolled. The patients were assigned to either early intervention (n = 55) or usual treatment (n = 65). Patients assigned to the intervention were given a pamphlet called “Living with Advanced Cancer” and had a discussion with a psychologist. The primary endpoint of the study was the proportion of patients with do-not-resuscitate (DNR) orders in place, the timing of these orders, and the place of death.

The results showed that there was a similar rate of DNRs between the two study groups; however, patients assigned to the intervention had DNRs in place a median of 27 days before death compared with 12.5 days before death among patients given usual care (P = .03). In addition, only 19% of patients assigned to the intervention died in the hospital compared with 50% of patients given usual care (P = .004).

A secondary analysis showed that there were no significant changes in the rate of depression or anxiety between patients in the two groups. However, results did show that there was less burden to caregivers’ schedules when patients were given the end-of-life intervention.

“The findings were not surprising, in that we predicted these outcomes,” Sharpe said. “However, given that much larger studies had failed to influence these outcomes, the findings are definitely encouraging and suggest that one can encourage the patients to share in their own end-of-life decision-making, and influence the degree to which they do so.”