It is a natural inclination to want to prolong life, for however short a time. That’s why terminally ill cancer patients will often choose chemotherapy even though it may reduce their quality of life (QOL), say researchers from Harvard Medical School in Boston, Massachusetts, and Weill Cornell Medical College in New York, New York. And those wishes are honored, the researchers say: As many as 50% of patients with incurable cancers receive chemotherapy within 30 days of death, “despite growing concerns that it may not be effective.”
The researchers analyzed data from Coping With Cancer, a prospective, longitudinal study of patients with advanced cancer at 8 outpatient oncology clinics in the U.S. Of 386 patients, 56% were receiving palliative chemotherapy when they enrolled in the study. Those patients were more likely to choose life-extending care over comfort care, including chemotherapy, if it might add as little as 1 week to their life. Patients receiving palliative chemotherapy were less likely to acknowledge that their illness was terminal, compared with patients who were not receiving chemotherapy (35% vs 49%). They were also less likely to report that they had discussed their end-of-life wishes with a physician or to have completed a do not resuscitate order than were the patients who were not receiving chemotherapy (36% vs 49%).
However, the patients who received palliative chemotherapy were also much more likely to receive cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% vs 2%) and twice as likely to be fed through a feeding tube in the last week of life (11% vs 5%), compared with patients who were not receiving chemotherapy. In addition, patients who received palliative chemotherapy were more likely to be referred late to hospice: 54% were enrolled within 1 week of death, compared with 37% of patients not on palliative chemotherapy.
Further, the choice of palliative chemotherapy meant that patients were more likely to die in an intensive care unit than at home or another preferred place (11% vs 2%, respectively). This is the first study, the researchers believe, to examine the associations between use of palliative chemotherapy and patients’ location of death. All those factors have been associated with worse QOL for patients at the end of life, more distress for their caregivers, and higher costs, the researchers say.
In this study, although only 40% of terminally ill patients receiving palliative chemotherapy preferred life-extending medical care to care that focused on relieving pain and discomfort, 86% preferred chemotherapy if it would give them 1 more week—but so did 60% of patients not receiving chemotherapy.
Many patients choose chemotherapy, though, because they have not been told about other options. This can be a difficult conversation, especially because both patients and physicians, the researchers note, may equate stopping treatment with “giving up” or “doing nothing.” But this study found no difference in survival between patients who received palliative chemotherapy and those who did not. That finding is a reminder, the researchers say, “that palliative chemotherapy does not necessarily extend life….[C]ontinuing treatment should not come at the cost of engaging in advance care planning” to ensure that “patients’ end-of-life experiences are congruent with their values.”
Source
Wright AA, Zhang B, Keating NL, Weeks JC, Prigerson HG. BMJ. 2014;348:g1219.
doi: 10.1136/bmj.g1219.
