Discussing end-of-life treatment options: advanced cancer vs. amyotrophic lateral sclerosis

Abstract

8065 Background: Patients with advanced cancer need information about treatment options if they are to make informed decisions about end-of-life care. Clinicians sometimes avoid these discussions. Methods: As part of a long-term longitudinal study, we interviewed patients with advanced gastrointestinal or lung cancer and an expected 2-year survival of < 50% (CA) and patients with recently diagnosed amyotrophic lateral sclerosis (ALS). We reviewed each patient’s out-patient chart at enrollment and at three months for evidence of discussion of patient wishes concerning ventilator support (VS), artificial nutrition and hydration (ANH), resuscitation (DNR), and hospice care (HC), comparing CA patients with ALS patients using the Fisher’s or the χ2 tests. We also performed a Kaplan-Meier analysis and calculated 2 year survival. Results: We enrolled 60 CA patients and 32 ALS patients. Mean patient age was 62 for CA and 62 for ALS. Sixty-two percent of CA patients were male vs. 56% for ALS (NS). Seventy-one percent of CA patients were white vs. 94% for ALS (p = .01). ALS patients were significantly more likely than CA patients to have evidence of a discussion about their wishes for VS (35% vs.0%, p < .001), ANH (40% vs. 0%, p < .001), DNR (29% vs. 0%, p < .001), and HC (25% v. 5%, p = .03). At six months, 91% of ALS patients were alive vs. 62% of CA; at two years 63% of ALS patients were alive vs. 23% of CA, (p < .001). Conclusions: CA patients were less likely than ALS patients to have had an out-patient discussion about VS, ANH, DNR, and HC despite having a significantly worse survival outcome. This may reflect a perception that ALS has a more predictable downhill course than advanced CA, a greater number of treatment options for advanced CA compared with ALS, or differing views about hope. The lack of documented discussion of end-of-life treatment options in this group of poor prognosis CA patients may nevertheless leave CA patients less adequately prepared for end-of-life decision-making and/or forced to confront these difficult issues only when hospitalized and close to death. No significant financial relationships to disclose.