A growing body of evidence points to the use of chemotherapy at end of life as a measure of poor quality of care overall, and, more specifically, poor quality end-of-life care, according to speakers who discussed the topic at a practice management session at the 2015 American Society of Clinical Oncology annual meeting.
As cancer therapeutics have improved, the historical appropriateness of end-of-life chemotherapy has become less clear. Acknowledging prognostic uncertainty as good news remains important, and novel therapies have helped to increase the level of prognostic uncertainty.
“Cancer therapies are becoming more effective and less toxic,” said Jennifer S. Temel, MD, Clinical Director of Thoracic Oncology, Massachusetts General Hospital Cancer Center, Boston. “Newer FDA-approved therapies can be effective, even for patients with poor functional and performance status. It is unclear if the ‘no chemotherapy for PS3’ rule is still relevant for these newer therapies.
“However, we must still acknowledge when patients have incurable disease, and when the goal of treatment is to prolong life rather than cure,” she added.
Improved patient–clinician communication about end of life has become essential to overall improvement in end-of-life care, said Dr Temel. Patients who have not had meaningful discussions with clinicians about end-of-life care—including chemotherapy, cardiopulmonary resuscitation, and referral for hospice care—have an increased likelihood of receiving inappropriate, aggressive care at the end of life.
Despite its historical support, the use of chemotherapy at the end of life as a quality metric has become problematic. Metrics that look backward retrospectively from death assume that healthcare providers “know” that the patient was within weeks or months of death, said Dr Temel.
However, administrative data used for such studies cannot distinguish relatively healthy patients who died unexpectedly from patients with poor performance status. Moreover, such data cannot identify those rare patients who are well-informed and still express a preference for chemotherapy at the end of life.
Struggles with end-of-life decisions almost inevitably involve poor communication.1,2
“We often defer discussions with our patients about their prognosis, treatment intent, and end-of-life care,” said Dr Temel. “Chemotherapy at the end of life is one of many downstream effects of this poor communication.”
Recent studies have shown that patients and family members value communication about terminal illness.3,4 Data also support the view that end-of-life discussions are associated with less aggressive care.2
“It is essential that we improve our communication with patients about their illness and prognosis,” said Dr Temel. “Patients must understand when they have incurable disease, and when the intent of their treatment is not curative, regardless of their prognosis and the availability of therapies. We cannot defer discussions with patients about their prognosis and care preferences until the end of life.”
Good communication leads to improved adherence to therapy and patient satisfaction and fewer complaints and lawsuits, said Thomas LeBlanc, MD, Palliative Care Specialist at Duke University in Durham, NC. Discussions about end-of-life care are associated with acknowledgment of terminal illness, a preference for comfort care over life extension, receipt of less intensive care aimed at prolonging life, and more palliative treatment, with provision of care that is consistent with patient and family preferences.5
Evidence-based strategies have emerged to guide clinicians in their engagement with patients and families in meaningful discussions about end-of-life care, said Dr LeBlanc. The overarching objective is to achieve a balance between honesty and empathy. Yet, oncology providers too often overlook or ignore opportunities to express empathy. For example, a study of 290 patients with advanced cancer and 51 oncologists showed that 37% of the conversations offered at least one opportunity for empathy, but providers responded empathetically 22% of the time.6
Empathetic conversation is associated with reduced patient anxiety and improved psychological adjustment. Provider response to emotional cues is associated with improved patient recall, whereas “distancing responses” are associated with less recall.7,8
According to Dr LeBlanc, a model for good provider communication consists of 4 key elements:
- Assessment of preferences for communication
- Seeking permission to communicate
- Provision of information in small amounts
- Attention to emotion.
“Communication skills are measurable, learnable, and teachable,” he added. “Like any skill, communication must be practiced and consciously honed over time.”
- Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.
- Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300:1665-1673.
- Yun YH, Lee CG, Kim SY, et al. The attitudes of cancer patients and their families toward the disclosure of terminal illness. J Clin Oncol. 2004;22:307-314.
- El-Jawahri A, Traeger L, Park ER, et al. Associations among prognostic understanding, quality of life, and mood in patients with advanced cancer. Cancer. 2014;120:278-285.
- Trice ED, Prigerson HG. Communication in end-stage cancer: review of the literature and future research. J Health Commun. 2009;14(suppl 1):95-108.
- Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol. 2007;25:5748-5752.
- Dimoska A, Butow PN, Dent E, et al. An examination of the initial cancer consultation of medical and radiation oncologists using the Cancode interaction analysis system. Br J Cancer. 2008;98:1508-1514.
- Jansen J, van Weert JC, de Groot J, et al. Emotional and informational patient cues: the impact of nurses’ responses on recall. Patient Educ Couns. 2010;79:218-224.