The Remington Report

Despite guidelines recommending that physicians discuss end-of-life options with terminally ill patients who have less than a year to live, most who see cancer patients would not do so as long as their patients are feeling well, according to a new study published in CANCER, a peer-reviewed journal of the American Cancer Society.

According to the nationwide survey, physicians would wait for symptoms to develop or until there are no more treatments to offer. National guidelines recommend discussions of end-of-life issues when patients have limited time left so that patients’ preferences can be met. Some evidence suggests that when these discussions occur, individuals have better experiences with death. To determine the extent to which physicians follow these recommendations, researchers surveyed a national sample of 4,074 physicians who care for cancer patients. The survey questioned physicians about end-of-life issue discussions – prognosis, preferences for resuscitation, hospice care, etc. – with patients who had four to six months to live but who were currently feeling well.

The study found that:

• While 65 percent of physicians would discuss prognosis now, fewer would discuss patients’ preferences for resuscitation (44 percent), hospice (26 percent) or where patients would like to die (21 percent). Instead, most would wait until patients felt worse or until no more treatment options were available.

• Younger physicians and physicians who were not cancer specialists would discuss end-of-life options sooner than older doctors and cancer specialists.

• Physicians caring for patients in HMO or Veterans Affairs (VA) settings were more likely to start end-of-life discussions earlier than physicians who cared for patients in other settings.

Further research is needed to understand doctors’ reasons for putting off end-of-life discussions with terminally ill cancer patients who are feeling well, said Nancy Keating, M.D., M.P.H., of the Brigham and Women’s Hospital and Harvard Medical School in Boston. “Most physicians may delay end-of-life discussions because they are difficult and time-consuming,” said Dr. Keating. She noted that it is also possible that physicians disagree with the guidelines, which are based primarily on expert consensus because data are limited.