The conclusion of this unique study may seem counterintuitive, but it isn’t. Once the end of life is clearly in sight — when the patient has weeks, days, or hours to live — extraordinary means to extend life do little to improve the mental outlook of the patient and may contribute to panic and depression.
Patients dying of cancer have a better quality of life towards the end if aggressive, life-prolonging measures are avoided and if they are able to die at home, a multicenter study suggested.
Being admitted to the intensive care unit during the last week of life was the strongest negative factor, accounting for −4.4% of variance in patients’ quality of life, according to Holly G. Prigerson, PhD, and colleagues from Harvard University in Boston.
Also strongly influential was in-hospital death, which explained an additional −2.7% of the variance, the researchers reported online in Archives of Internal Medicine.
Although some earlier research has focused on general aspects of end-of-life care, such as pain management and physician responsiveness, the specific factors that matter most to patients with terminal cancer and their families have not been fully explored, the researchers said.
“The concept of quality of the [end of life] in cancer patients has been underexamined in cancer medicine in the quest to develop newer, more advanced, and effective modalities of interventional cytotoxic therapies,” wrote Alan B. Zonderman, PhD, and Michele K. Evans, MD, of the National Institute on Aging in Baltimore, in an invited commentary.
To this end, a prospective study termed Coping With Cancer has been examining the concerns of a wide variety of patients and their caregivers, who were interviewed at baseline about sociodemographic factors, physical and psychological status, treatment preferences, and support structures.
The factors in improving quality of life for the dying — and those that are detrimental — depend on how aggressive treatment to extend life might be.
(Zero and above improves quality of life)
Pastoral care in the hospital or clinic, 1.60 (P=0.052)
Therapeutic alliance with physician, 1.45 (P=0.09)
Intensive care unit stay, −5.61 (P<0.001)
Death in the hospital, −3.03 (P=0.003)
Religious activities prior to cancer diagnosis, 0.66 (P=0.005)
Worry or anxiousness, −0.39 (P=0.002)
Chemotherapy during the last week of life, −3.46 (P=0.04)
Feeding tube during the last week of life, −3.54 (P=0.03)
Another factor is the attitude of the physician:
“Physicians who are able to remain engaged and ‘present’ for their dying patients — by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings — have the capacity to improve a dying patient’s [quality of life],” Prigerson and colleagues stated.
The debate over end of life care is one that is going to become more and more contentious and necessary once baby boomers begin to reach the end stages of their lives and Medicare, which is billed for much of the extraordinary effort to extend life , begins to bankrupt the nation. About 25% of all Medicaid spending is dedicated to treating patients in the last year of their life and that number is expected to rise substantially in the next two decades. Even if Obamacare is repealed, this debate is going to happen and we are going to have to come to grips with a problem that doesn’t appear to have a satisfactory solution.
The issue goes to the core of the western way of death; our attitudes toward extending life; the love of our families; the care and concern of the medical profession; and the unanswerable question of how to apply medical resources to the dying that is both compassionate and cost effective.
The norming of death panels.
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“Lastday, Capricorn 29′s. Year of the City: 2274. Carousel begins.”
Here’s the big question most of those who raise this issue avoid: how do you know if it’s the end? If a poor 30 year old person on Medicaid goes into the hospital with multiple gunshot wounds and the surgeons spend hours trying to save him, but ultimately fail, I imagine that would be very expensive and go into those expenditures in the last year of life statistics. Should the doctors have let the person die? Obama’s grandmother had a hip replacement less than a year before she died. He said that she should have just taken “a pain pill.” What if she had lived to the age of 92? I know someone whose mother had been diagnosed with terminal cancer, had ceased cancer treatments, and went into the hospital with kidney failure. The doctors saw on her x-ray that the tumor was presuring her kidney and they went into surgery to correct it. When they opened her up, the cancer was so bad they gave up. She went into a coma and died a week later. Under the circumstances, I think it was nuts to put her into surgery. However, I rather have patients and their families make that decision. Most cases are not going to be that clear cut. Personally, I think most people who cite that statistic about medical expenditures in the last year of life simply think the old should die and go away. On average, medical expenses are going to be highest in the last year of life. Why? Because like a person with multiple gunshot wounds that’s when people are most in need of care. Sometimes medical treatment can save someone and sometimes it can’t. If this study was focused on those with truly terminal cancer, it’s valuable to get people in that condition to think about their end of life care and to find the best ways to deal with it. However, unless we tell the eldery to die quickly, it’s not going to make any dent in our national healthcare expenditures no matter how much of a “debate” we have.
“I think most people who cite that statistic about medical expenditures in the last year of life simply think the old should die and go away.”
Shallow thinking. How can you possibly extrapolate that conclusion from simply citing the truth?
And the point about “patients and families” making the decision will be moot in the future. Someone has to pay for that decision. And if the families can afford a million dollars worth of end of life care – not uncommon – more power to them. But projecting costs outward, using all the Medicare funds a family might desire for the vast majority of dying patients will not be possible. There won’t be enough workers paying into the fund and we will be spending 2/3 of federal budget on Medicare alone.
Someday, something is going to have to give. And people like yourself — unwittingly — are going to make it necessary for government to step in and say how much care we get at the end because you and others like you refuse to face up to realities that will be upon us in a matter of years.
Right now, it’s a choice. Later on, that choice will be gone.
“Shallow thinking. How can you possibly extrapolate that conclusion from simply citing the truth?” Because people who cite the statistic, and you seem to be one, seem to cite the statistic with the underlying assumption that we can know who is in their last year of life. If someone has late stage terminal cancer, perhaps, in most other cases, probably not. I doubt if Obama’s grandmother knew she would be dead in less than one year when she opted to have her hip replaced. If you don’t know who is going to die soon, imposing limits on care means that many people, mostly the elderly, will be pushed into an early death. If you don’t like the idea of patients and families making treatment decisions, who, other than the government would do it?
I think you have to watch the semantics of these discussions very closely. The best decisionmaking will always be limited to the patient, physician and (a hopefully loving) family. Comfort care giving is a plus; heroic therapeutic interventions, probably not; relief of pain, always. No role here for hospital “ethicists”, hospital or government death panels, or government period.
This nation needs to get back to basics…in everything.
Discussion is a good thing. Getting information is great.
But there is no reason “We” all have to decide what “We” all think is best for “everyone.”
It’s not for “We” to decide any one-size fits all program.
I agree with # 3 – John C. Key, M.D. above.
No arguing that end of life care needs to be further discussed. However, it is references to studies like this that tend to dramatically oversimplify and even mislead casual readers.
According to the study, the factors identified account for less than 20% of the variation between the baseline QOL and the end of life measurement – meaning that over 80% of the difference is left unexplained by the study. Therefore, how actionable are these results? And how valid is the headlne of this article? Yet to be determined.