Patients Benefit From End-of-Life Discussions With a Doctor
TUESDAY Oct. 7, 2008 -- End-of-life discussions between a doctor and a terminally ill patient do not result in more distress for patients. In fact, they result in less aggressive medical interventions and enhanced quality of life in a patient's final days, a major new study found.
"For the past two decades, the debate has been around when, whether and how to have end-of-life conversations, but it wasn't clear if it was worth it," said study lead author Dr. Alexi A. Wright, a hematology-oncology fellow and research scholar at the Center for Psycho-Oncology and Palliative Care Research, both at Dana-Farber Cancer Institute in Boston. "This study is the first to look at outcomes and quality of life."
"A lot of doctors are afraid they will rob patients of hope if they have these conversations," Wright added. "But there's the possibility that the patient may be robbed of the opportunity to make informed decisions and live the life they want."
Experts had been concerned that such conversations might increase a patient's despondency and anxiety. This left doctors and other health-care providers relying heavily on avoidance tactics.
For the new study, the researchers interviewed 332 pairs of dying patients -- all of whom had advanced cancer -- and their informal caregivers. The median time from enrolment in the study to death was 4.4 months. The caregivers' psychological state and quality of life was assessed about 6.5 months after the patient's death.
At the start of the study, 37 percent of the patients said they'd had end-of-life discussions with their doctor. Contrary to expectations, these talks did not increase the rates of depression or worry.
And those patients who did have such talks with their physician had lower rates of ventilation (1.6 percent versus 11 percent); resuscitation (0.8 percent versus 6.7 percent) and admission to the intensive care unit (4.1 percent versus 12.4 percent). These patients also enrolled in a hospice earlier; longer hospice stays were associated with better quality of life, while aggressive medical care had the opposite effect, the study found.
Meanwhile, caregivers were significantly less likely to experience major depressive disorders if the loved one did not die in an intensive care unit.
One previous study, published last year in the New England Journal of Medicine, had found that when doctors spend 10 minutes more than usual listening to the families of people dying in the intensive care unit and provide them with a brochure on bereavement, those family members are far less likely to suffer from stress, anxiety or depression after the death of their loved one.
"This really highlights the importance of patients having end-of-life discussions with a health-care professional," said Dr. Robert McCann, professor of medicine at the University of Rochester School of Medicine and Dentistry and chief of medicine at Highland Hospital in Rochester, N.Y. "Just by having discussions -- we don't know anything about the quality of the discussion or what was said -- led patients to better choices, things that would make a bigger difference in quality of life."
For the physician, Wright said: "It's important to have a healthy dose of empathy and frank truth, ask the patient if they have thought about what this really means. Mental and physical health often deteriorate rapidly at the end, and this can leave health-care providers and loved ones wondering what the patient would have wanted."
The National Hospice and Palliative Care Organization has more on end-of-life care.
Posted: October 2008
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