Aggressive End-Of-Life Care Growing Trend In Cancer Patients With Terminal Disease
Recent advances in cancer therapy have proven to be double-edged swords. While they certainly have extended the lives of many patients, these often-aggressive treatments routinely result in hospital, emergency room, and intensive care unit admissions. The intensive use of chemotherapy, for example, has contributed to an increasing number of cancer survivors. But it has also resulted in more terminally ill patients with cancer, many of whom are receiving the same aggressive treatments as those who are not terminal.
Recently, a group of researchers set out to characterize this trend toward aggressive treatment of terminally ill cancer patients. In particular, they wanted to know whether this trend was on the rise, and if so, what relationship it had, if any, to the availability of hospice care. (Hospice focuses on caring, not curing, in an effort to keep dying patients comfortable while providing them and their families with emotional and spiritual support.) The results of their study were published in the January 15th issue of the Journal of Clinical Oncology. The researchers found that the trend toward aggressively treating terminally ill cancer patients was indeed on the rise, and that it seemed to be occurring more often where there was less access to hospice care.
About the study
The researchers reviewed the records of 28,777 Medicare-eligible patients aged 65 or older who all died within one year of receiving a diagnosis of lung, breast, colorectal, or other gastrointestinal cancers between 1993 and 1996.
The researchers found that there is a trend toward increasingly aggressive care in terminally ill cancer patients who are near death. For example, the study found that the rate of treatment with chemotherapy in these patients increased from 27.9% to 29.5%. They also found that among those who received the chemotherapy, 15.7% were still receiving treatment within two weeks of their deaths.
In addition, the number of patients who were admitted to the emergency room more than once, were hospitalized, or were admitted to the intensive care unit also increased from 7.2% to 9.2%, from 7.8% to 9.1%, and from 7.1% to 9.4%, respectively.
And, while the number of patients dying in acute-care centers dropped (32.9% to 29.5%), and the number of patients receiving hospice care services increased (28.3% to 38.8%), many patients did not receive hospice care until the last three days of their lives.
How does this affect you?
Although aggressive treatment of terminally ill cancer patients is on the rise, the availability of hospice care also appears to be increasing. Terminally ill patients who had access to hospice care were less likely to receive aggressive treatment for their disease, leading researchers to believe that if hospice care were more readily available in all areas of the country, it may reduce the use of aggressive intervention for terminally ill patients and improve the quality of care they receive.
In addition, although there is a general increase in the overall number of terminally ill cancer patients receiving hospice care, the researchers note that in most cases, this is not occurring until the patient is close to death, leading the researchers to conclude that hospice care, where it does exist, is being used more often to manage death, than to palliate the disease.
Having identified these trends, the researchers acknowledge that the next question is whether aggressive treatment has positive effects on either the survival of the patients or their quality of life. Obviously, decisions about end-of-life-care are personal, and the choice to continue to treat a terminally ill patient aggressively must ultimately lay with the patient and his or her family. But, these choices should be made on the basis of personal preference, not availability of services. Greater accessibility to hospice care may help ease an already difficult decision and help everyone involved strike a balance between access to potentially beneficial treatments and the kind of supportive care we all deserve at the end of our lives.
National Hospice and Palliative Care Organization
Promoting Excellence in End-Of-Life-Care
Cancer facts and figures 2003. American Cancer Society (ACS).
Available at: http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf . Accessed January 14, 2004.
Earle CC, Neville BA, Landrum MB, et al. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 22:315-321.
What is hospice and palliative care? National Hospice and Palliative Care Organization. Available at: http://www.nhpco.org/i4a/pages/index.cfm?pageid=3281 . Accessed January 14, 2004.
Last reviewed Jan 16, 2004 by ]]>Richard Glickman-Simon, MD]]>
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