Tuesday, June 17, 2008

'Most cancer doctors avoid saying it's the end'

A new study finds that only one-third of terminally ill patients had discussed end-of-life care. Those who did, the study found, were no more likely to become depressed than those who did not, and were less likely to spend their final days in hospitals on life-support equipment.

An AP article on the study explains:

The new study is the first to look at what happens to patients if they are or are not asked what kind of care they'd like to receive if they were dying, said lead researcher Dr. Alexi Wright of the Dana-Farber Cancer Institute in Boston.

It involved 603 people in Massachusetts, New Hampshire, Connecticut and Texas. All had failed chemotherapy for advanced cancer and had life expectancies of less than a year. They were interviewed at the start of the study and are being followed until their deaths. Records were used to document their care.

Of the 323 who have died so far, those who had end-of-life talks were three times less likely to spend their final week in intensive care, four times less likely to be on breathing machines, and six times less likely to be resuscitated.

About 7 percent of all patients in the study developed depression. Feeling nervous or worried was no more common among those who had end-of-life talks than those who did not.

WebMD offers more coverage of the study here.

So why are two-thirds of patients not having these conversations? My guess is first that many patients don't want them; everybody faces death differently, and cancer patients in particular carry a lot of excess linguistic and cultural baggage about "fighting" their disease. (Do people "fight" kidney disease or congestive heart failure?) In person, I often joke about the "I'm gonna beat this thing!" complex that stops some people from acknowledging the seriousness of their disease until the very end. I've written a little about how metaphors can support and undermine coping here (read the comments).

And, of course, we all know that many doctors will squirrel out on this kind of stuff out of misguided notions of what's good for their patients and a natural human desire to not say difficult, potentially upsetting things. (Physicians are also notoriously bad at estimating prognosis (see this tasty post for a link), often with a bias toward overestimating a patient's survival; perhaps they convince themselves they'll have time to break the bad news later?)

My thoughts: I wasn't surprised that terminally ill people benefited from frank conversations with doctors about end-of-life care. I was surprised so few people had those conversations.

My preliminary position is that doctors should understand that their patients are hugely resilient and capable of absorbing difficult truths. Obviously, timing is tricky and a doctor should never force his view of the situation on a patient, but tactfully acknowledging the elephant in the examining room is more likely to relieve stress than generate more.

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