Study Suggests Quality of Life Better with Less Care at the End
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.