Research published earlier this week in the Journal of Oncology highlighted how end-of-life conversations can affect treatment decisions. In a study involving 1,200 patients with advanced lung or colon cancer, those who had early end-of-life discussions with their physicians were less likely to receive aggressive care and more likely to receive hospice care in their last days.
Noting that the majority of patients had end-of-life discussions after they were already hospitalized, the authors suggested in the paper that "physicians should consider moving conversations closer to diagnosis and initiating conversations while the patient is doing comparatively well, so the patient has time to plan for more difficult times in the future."
Interested to know more about the importance and timing of end-of-life conversations, I reached out to VJ Periyakoil, MD, director of palliative care education and training at Stanford. She agreed that these conversations are often delayed far too long, and she shared her approach to discussing end-of-life care with patients:
Despite advances in modern medicine, our ability to prognosticate lifespan is not all that good. Physicians tend to be optimistic by a factor of three. Sadly, end-of-life is often a retrospective diagnosis. Thus we tend to do too little, too late in terms of educating the patient and the family. Conversations about end-of-life issues should ideally be done in a non-crisis situation while the patient and their surrogates are able to think clearly about options available and use their personal and family values as the blueprint to determine the choices they would make.
In approaching these conversations, I try to normalize the conversation and make patients and families feel safe by saying, "Next I want to talk about an important issue that I address with all my patients." Then, I tell them that we need to hope for the best and plan for the worst, so that we are ready for possible issues that may present themselves. To do this, I might say, "I hope that the chemotherapy works and you tolerate it well. I worry that I may not be educating you about how the possible side effects may erode your quality of life."
Early data show that when people feel better, they live longer. The upshot is we do not want to burden patients with ineffective technological interventions that prolong the dying process at the cost of quality of life, such as hospitalizing a patient for chemotherapy treatments when they really want to be at home with their loved ones.
Previously: A Stanford nurse shares her experience in talking to her aging mother about end-of-life decisions, Talking about a loved one’s end-of-life wishes, Helping caregivers practice palliative care and Examining the generational gap between physicians and patients in hospice and palliative care
Photo by Lee Haywood