Changes of End of Life Practices for Cancer Patients and Their Association with Hospice Palliative Care Referral over 2009-2014: A Single Institution Study

Abstract

Purpose In Korea, hospice palliative care (HPC) provision for cancer patients has increased recently. However, whether end of life (EoL) care practices have improved along with the development of HPC is unclear. We intended to investigate the changes in EoL care practices and their association with HPC referral. Materials and Methods Retrospective medical record review of adult cancer patients who died at National Cancer Center Korea from 1 January 2009 to 31 December 2014 was performed. Changes of EoL practices including chemotherapy within 2 weeks from death, death in intensive care unit (ICU), documentation of “do not resuscitate (DNR)” within 7 days from death and referral to HPC from 2009 to 2014 were analyzed as well as the association between referral to HPC and other practices. Results A total of 2,377 cases were included in the analysis. Between 2009 and 2014, referral to HPC increased and DNR documentation within 7 days from death decreased significantly. Cases for chemotherapy within 2 weeks from death and death in ICU didn’t change over the study period. Patients referred to HPC were less likely to receive chemotherapy within 2 weeks from death, die in ICU and document DNR within 7 days from death. Conclusion During the study period, EoL practices among cancer patients partly changed toward less aggressive in our institution. HPC referral was associated with less aggressive cancer care at the EoL. Policies to promote EoL discussion are necessary to improve the EoL practices of cancer patients.

Changes in End-of-Life Discussion for Patients with Advanced Cancer after the Life- Sustaining Treatment Decisions-Making Act in Korea

“…Additionally, the rate of self-determination was high at 63.5% in our study population, compared to the rate of 30% from other Korean analyses conducted at a similar time [19,23]. This high rate of self-determination could be interpreted as having been activated by the HPC referral system of Ulsan University Hospital which offers inpatient HPC units and home hospice services.…”

Implication of the Life-Sustaining Treatment Decisions Act on End-of-Life Care for Korean Terminal Patients

“…Although decision making occurs earlier than before [ 24 , 25 ] given that the interval from advance statement to death was median of 33 days, it does not seem sufficient enough for all the patients to be able to make decision themselves. Additionally, in Korea, DNR orders are usually written in a week before dying [ 7 , 9 , 15 ], which means that most of them are documented without proper ACP. To be more effective, we should consider initiating ACP discussion when a patient is diagnosed with critical or terminal illness [ 17 , 26 ].…”

“…It is important for a person to prepare an EOL care plan aligning with one’s own wishes, values, and beliefs [ 6 ]. However, in Korea, several studies on terminal cancer patients show that EOL discussions commonly take place when death is imminent or even when cardiac arrest occurs and it is too late for the patient to have input [ 7 - 9 ], so the EOL discussions mainly occur between physicians and family caregivers [ 7 , 8 , 10 , 11 ]. Therefore, patients’ intents regarding life-sustaining treatment (LST) cannot be respected.…”

Difficulties doctors experience during life-sustaining treatment discussion after enactment of the Life-Sustaining Treatment Decisions Act: A cross-sectional study

“…Decisions for LST in Korea are mostly discussed within a few days or weeks before death (4)(5)(6). Family members usually write a do-not-resuscitate document as surrogate decision makers for family members near death (5)(6)(7)(8).…”