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Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment
Alexi A. Wright, MD;
Baohui Zhang, MS;
Alaka Ray, MD;
Jennifer W. Mack, MD, MPH;
Elizabeth Trice, MD, PhD;
Tracy Balboni, MD, MPH;
Susan L. Mitchell, MD;
Vicki A. Jackson, MD, MPH;
Susan D. Block, MD;
Paul K. Maciejewski, PhD;
Holly G. Prigerson, PhD
JAMA. 2008;300(14):1665-1673.
Context Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.
Objective To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.
Design, Setting, and Participants A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.
Main Outcome Measures Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.
Results One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (β = .20; P = .001).
Conclusions End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.
Author Affiliations: Department of Medical Oncology (Drs Wright and Trice), Center for Psycho-Oncology and Palliative Care Research (Drs Wright, Ray, Trice, Balboni, Block, and Prigerson and Ms Zhang), Department of Pediatric Oncology (Dr Mack), and Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston; Massachusetts General Hospital, Boston (Drs Ray and Jackson), Harvard Radiation Oncology Program (Dr Balboni), Harvard Medical School Center for Palliative Care (Drs Jackson, Block, and Prigerson), Harvard University, Boston; Institute for Aging Research, Hebrew SeniorLife, Roslindale (Dr Mitchell); Beth Israel Deaconess Medical Center, Boston (Drs Mitchell); and Department of Psychiatry, Brigham and Women's Hospital, Boston (Drs Block, Maciejewski, and Prigerson).
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