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Ever cared for that patient with metastatic cancer in your ICU, intubated for acute respiratory failure and surrounded by a bewildered and stressed family who cope by emotionally blaming you, the intensivist, because "He just saw his oncologist last week, and he said everything was OK!"? Forcing you to begin painful end-of-life discussions that should have happened months ago with the oncologist the patient knows and trusts?
(Or worse yet, starting this difficult process, then having the oncologist come around to say "if we can just get him through this ARDS and multi-organ failure, I can give him some more chemotherapy!")
Well, it's not just you (and I), as it turns out.
Jennifer Mack, Angel Cronin, and Jane Weeks followed 2,155 patients with metastatic lung or colorectal cancer in 4 states across the U.S., for 15 months after their diagnosis with stage IV cancer, using the CanCORS registry. They reported their results in the February 7 Annals of Internal Medicine.
Most of these patients did get end-of-life conversations -- but with physicians other than their oncologists, and often shortly before their deaths:
- Almost 90% of the 1,470 patients who died during follow-up received end-of-life discussions.
- More than half of the initial end of life discussions occurred in a hospital.
- Half of end of life discussions took place one month or less before death.
- Oncologists documented end of life discussions in the hospital charts of only 27% of their patients hospitalized with an acute illness after a diagnosis of stage IV, incurable, metastatic lung or colorectal cancer. Most of the time, it was another physician (the hospitalist or intensivist) who documented the discussion.
Oncology guidelines recommend physicians discuss end of life preferences and palliative care options with patients with incurable cancer with life expectancy less than one year. Limited evidence in patients with metastatic lung cancer (Ternel, NEJM 2010) shows that such an approach can actually prolong survival, compared to standard (i.e., aggressive) medical care.
Mack JW et al. End-of-Life Care Discussions Among Patients With Advanced Cancer. A Cohort Study. Ann Intern Med 2012;156:204-210.