Medical care and emotional distress associated with advanced cancer patients' end-of-life discussions with their physicians

Abstract

6505 Background: Physicians are concerned that end-of-life (EOL) discussions may distress terminally ill patients, and may not offer benefit. Little is known, however, about whether EOL discussions are associated with psychological distress and medical care received at the EOL. Methods: Coping with Cancer (CwC) is an NCI/NIMH-funded, prospective, longitudinal, multi-institutional study of 603 advanced cancer patients. Patients were interviewed on enrollment and followed until death; medical care received in the last week of life was obtained from chart review. Patients who reported having had EOL conversations were compared with those who did not on their degree of emotional distress [e.g. severity of psychological symptoms such as worry and rates of Major Depressive Disorder (MDD) using the Structured Clinical Interview for DSM-IV], terminal illness acknowledgement, treatment preferences, and medical care. Results: 188 of 603 patients (31.2%) reported EOL discussions with physicians. No mental health differences were found. Patients reporting EOL discussions were not more likely to meet criteria for MDD [rates were 7.2% vs. 7.4%, odds ratio (OR)=0.98, 95% confidence interval (CI) 0.50–1.90] or feel “nervous or worried” [adjusted least mean squares 2.81 vs. 2.77, t=-0.16, p=0.87]. They were more likely to acknowledge being terminally ill [adjusted OR (AOR)=2.24, CI 1.45–3.44], value comfort care over life extension (AOR=3.23, CI 2.02–5.17), and complete a DNR order (AOR= 3.62, CI 2.36–5.56). Among the 323 CwC decedents, patients reporting EOL conversations were less likely to undergo ventilation (AOR= 0.04, CI 0.004–0.43) or ICU admission (AOR= 0.21, CI 0.05–0.88), and more likely to receive hospice (AOR=2.13, CI 1.13–4.02). After propensity score matching, lower rates of ICU admission (AOR 0.21, CI 0.05–0.88) and ventilation (AOR 0.11, CI 0.01–0.87) remained. Conclusions: EOL care discussions between physicians and patients with advanced cancer are not associated with psychological distress. Furthermore, these discussions may result in increased patient understanding of illness severity, fewer invasive procedures, and lower rates of ICU admission at the EOL. No significant financial relationships to disclose.