Opportunity lost: end-of-life discussions in cancer patients who die in the hospital

J Hosp Med. 2013 Jun;8(6):334-40. doi: 10.1002/jhm.1989. Epub 2012 Nov 20.


Background: End-of-life discussions are associated with decreased use of life-sustaining treatments in patients dying of cancer in the outpatient setting, but little is known about discussions that take place during terminal hospitalizations.

Objectives: To determine the proportion of patients assessed by the clinical team to have decisional capacity on admission, how many of these patients participated or had a surrogate participate in a discussion about end-of-life care, and whether patient participation was associated with treatments received.

Design: Retrospective review.

Setting: Inpatient.

Patients: Adult patients with advanced cancer who died in the hospital between January 1, 2004 and December 31, 2007.

Results: Of the 145 inpatients meeting inclusion criteria, 115 patients (79%) were documented to have decisional capacity on admission. Among these patients, 46 (40%) were documented to lose decisional capacity prior to an end-of-life discussion and had the discussion held instead by a surrogate. Patients who had surrogate participation in the end-of-life discussions were more likely to receive mechanical ventilation (56.5% vs 23.2%, P < 0.01), artificial nutrition (45.7% vs 25.0%, P = 0.03), chemotherapy (39.1% vs 5.4%, P <0.01), and intensive care unit (ICU) treatment (56.5% vs 23.2%, P <0.01) compared to patients who participated in discussions. There was no difference between palliative treatments received.

Conclusion: The majority of patients with advanced cancer are considered to have decisional capacity at the time of their terminal hospitalization. Many lose decisional capacity before having an end-of-life discussion and have surrogate decision-makers participate in these discussions. These patients received more aggressive life-sustaining treatments prior to death and represent a missed opportunity to improve end-of-life care.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cohort Studies
  • Female
  • Hospital Mortality*
  • Humans
  • Male
  • Neoplasms / mortality*
  • Neoplasms / psychology
  • Neoplasms / therapy*
  • Palliative Care / methods
  • Palliative Care / psychology
  • Palliative Care / standards*
  • Patient Participation* / methods
  • Patient Participation* / psychology
  • Registries
  • Retrospective Studies
  • Terminal Care / methods
  • Terminal Care / psychology
  • Terminal Care / standards*