A prospective cohort study assessing aggressive interventions at the end-of-life among patients with solid metastatic cancer

Abstract

Background Many patients with a solid metastatic cancer are treated aggressively during their last month of life. Using data from a large prospective cohort study of patients with an advanced cancer, we aimed to assess the number and predictors of aggressive interventions during last month of life among patients with solid metastatic cancer and its association with bereaved caregivers’ outcomes. Methods We used data of 345 deceased patients from a prospective cohort study of 600 patients. We surveyed patients every 3 months until death for their physical, psychological and functional health, end-of-life care preference and palliative care use. We surveyed their bereaved caregivers 8 weeks after patients’ death regarding their preparedness about patient’s death, regret about patient’s end-of-life care and mood over the last week. Patient data was merged with medical records to assess aggressive interventions received including hospital death and use of anti-cancer treatment, more than 14 days in hospital, more than one hospital admission, more than one emergency room visit and at least one intensive care unit admission, all within the last month of life. Results 69% of patients received at least one aggressive intervention during last month of life. Patients hospitalized during the last 2–12 months of life, male patients, Buddhist or Taoist, and with breast or respiratory cancer received more aggressive interventions in last month of life. Patients with worse functional health prior to their last month of life received fewer aggressive interventions in last month of life. Bereaved caregivers of patients receiving more aggressive interventions reported feeling less prepared for patients’ death. Conclusion Findings suggest that intervening early in the sub-group of patients with history of hospitalization prior to their last month may reduce number of aggressive interventions during last month of life and ultimately positively influence caregivers’ preparedness for death during the bereavement phase. Trial registration NCT02850640.

What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials

“…Place of death is often considered an indicator of quality end-of-life care 162 163. It is based on the assumption that home deaths are less intrusive and are associated with lower healthcare costs 164 165.…”

“…Place of death is often considered an indicator of quality end-of-life care. 162 163 It is based on the assumption that home deaths are less intrusive and are associated with lower healthcare costs. 164 165 However, not all patients prefer a home death 155 157 166 and home deaths may not be feasible to achieve in many instances due to practical constraints.…”

Multifactorial risk factors for hospital readmissions among patients with symptoms of advanced heart failure

“…The role of patient preferences for life extension in predicting hospital readmissions has also been overlooked. This is despite studies suggesting that patients who prefer life extending treatments also receive more aggressive treatments 11 . The association between patient preferences for life extension and hospital readmissions may vary by patients' financial situation and healthcare affordability.…”

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“…Patient and caregiver goals of care are influenced by their characteristics. 17 Previous studies have shown that patients who were married, 18,19 experienced unplanned hospitalizations, 20,21 and faced higher financial difficulties 22 tended to prioritize life extension.…”

“…Patient and caregiver goals of care are influenced by their characteristics . Previous studies have shown that patients who were married, experienced unplanned hospitalizations, and faced higher financial difficulties tended to prioritize life extension. Conversely, older patients and those with a correct understanding of their prognosis, higher symptom burden, and greater spiritual well-being were more inclined toward prioritizing symptom management.…”