End-of-life care discussions among patients with advanced cancer: a cohort study

Abstract

Background: National guidelines recommend that physicians discuss end-of-life (EOL) care planning with patients with cancer whose life expectancy is less than 1 year.

Objective: To evaluate the incidence of EOL care discussions for patients with stage IV lung or colorectal cancer and where, when, and with whom these discussions take place.

Design: Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005.

Setting: Participants lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama or received care in 1 of 5 large HMOs or 1 of 15 Veterans Health Administration sites.

Patients: 2155 patients with stage IV lung or colorectal cancer.

Measurements: End-of-life care discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis.

Results: 73% of patients had EOL care discussions identified by at least 1 source. Among the 1470 patients who died during follow-up, 87% had EOL care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up. Of the 1081 first EOL care discussions documented in records, 55% occurred in the hospital. Oncologists documented EOL care discussions with only 27% of their patients. Among 959 patients with documented EOL care discussions who died during follow-up, discussions took place a median of 33 days before death.

Limitations: The depth and quality of EOL care discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained.

Conclusion: Although most patients with stage IV lung or colorectal cancer discuss EOL care planning with physicians before death, many discussions occur during acute hospital care, with providers other than oncologists, and late in the course of illness.

Primary funding source: National Cancer Institute and Department of Veterans Affairs.

Figure 1. Study design

Box plots show the median time from diagnosis to completion of baseline and follow up interviews.

Figure 2. Selection of analytic cohort

The CanCORS study’s response rate, which accounts for both unsuccessful contacts and refusal/non-response, was 51.0%. The cooperation rate, which does not account for unsuccessful contacts, was 59.9% (12). Please see definitions provided by the American Association for Public Opinion Research for details of calculation of response and cooperation rates (19).