Cancer Treatment Intensity Persists at End of Life

Better advance-care planning strategies are needed, including recognition by healthcare leaders of the importance and value of palliative care as a field, says a Johns Hopkins researcher.

With more and more attention being paid to end-of-life care and advanced care directives, aggressive treatments on dying patients are not correspondingly decreasing as expected.

"Our findings did not quite reflect that," says Amol Narang, MD, a resident in the department of radiation oncology and molecular radiation sciences at The Johns Hopkins Hospital, first author of new research published in JAMA Oncology.

The researchers analyzed survey data from nearly 2,000 next-of-kin surrogates of Health and Retirement Study participants with cancer who died between 2000 and 2012. Over the 12-year study period, there was a 40% increase in the number of patients with cancer who participated in designating durable power of attorney privileges to a loved one. That increase, however, wasn't associated with the patients receiving less aggressive medical treatment during the last few weeks of their lives.

"Several measures of treatment intensity at end of life continue to be very high, just as high as they were 10–15 years ago," Narang says.

Aggressive medical treatment for end-of-life included such factors as whether patients who were terminally ill with cancer died in the hospital, whether they visited the emergency department during the last few weeks of life, were admitted to the ICU shortly before death, and failed to be referred to hospice until right before death.

"We know that end of life care in cancer patients can be aggressive," he says.

In fact, a separate study also published this month in JAMA Oncology from researchers at Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Kaiser Permanente Southern California found that more than two-thirds of adolescents and young adults dying of cancer used one or more aggressive interventions in the last month of life.

"People want to always have hope," Narang says. And "these conversations can be uncomfortable."

In the Hopkins study, not only did researchers find that aggressive care continued despite having a durable power of attorney, but many survey respondents said they never discussed end-of-life preferences with their loved ones, physicians, or anyone else. They did not necessarily want such aggressive care but no one had talked about it.

"We were especially surprised by the fact that 40% of survey respondents... were indicating that the patient had never discussed their preferences for the care they wanted to receive with anyone," Narang says. "I think that that speaks toward the fact that assigning a power of attorney without communicating preferences… may not be an effective form of advance-care planning."

"I think it just clearly points to the fact that we need to do more to support better palliative care at end-of-life in cancer patients," he adds.

What could make for better planning and palliative care are physicians having these difficult conversations with patients and family members. Narang says he's hopeful that the proposed CMS payments for end-of-life conversations will help advanced planning become a "routine and integral aspect of end-of-life care" and of care for patients with a terminal outcome.

"I think the CMS proposal is an option; finance supporting these conversations can help increase their frequency," he says.

Other strategies to increase end-of-life planning and reduce the kind of aggressive care that many terminal patients likely don't want include expanding training in palliative care and increasing the number of outpatient palliative clinics.

"I think those two kind of go hand in hand," Narang says.

Making these conversations routine will also help ensure that they happen in a controlled setting where parties can discuss things openly, honestly, and calmly, "rather than in a more urgent setting when decisions have to be made quickly."

Hospital executives have a role to play, too, Narang says, by "recognizing the importance and the value of palliative care as a field," as well as hiring palliative care specialists; training providers so they feel comfortable having these discussions; and providing a physical clinic space where these kinds of conversations can happen.

"I think that there are a lot of influences," Narang says. "I think better understanding of that is worthy of future investigations."