Factors associated with the aggressiveness of care at the end of life for patients with cancer dying in hospital: a nationwide retrospective cohort study in mainland Portugal

Abstract

IntroductionThere is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL), defined as overly aggressive treatments that compromise the quality of life at its end. Recognising the most affected patients is a cornerstone to improve oncology care. Our aim is to identify factors associated with ACCEoL for patients with cancer dying in hospitals.MethodsAll adult patients with cancer who died in public hospitals in mainland Portugal (January 2010 to December 2015), identified from the hospital morbidity database. This database provided individual clinical and demographic data. We obtained hospital and region-level variables from a survey and National Statistics. The primary outcome is a composite ACCEoL measure of 16 indicators. We used multilevel random effects logistic regression modelling (p<0·05).ResultsWe included 92 155 patients: median age 73 years; 62% male; 53% with metastatic disease. ACCEoL prevalence was 71% (95% CI 70% to 71%). The most prevalent indicators were >14 days in the hospital (43%, 42–43) and surgery (28%, 28–28) in the last 30 days. Older age (p<0·001), breast cancer (OR 0·83; 95% CI 0·76 to 0·91), and metastatic disease (0·54; 95% CI 0·50 to 0·58) were negatively associated with ACCEoL. In contrast, higher Deyo-Charlson Comorbidity Index (p<0·001), gastrointestinal and haematological malignancies (p<0·001), and death at cancer centre (1·31; 95% CI 1·01 to 1·72) or hospital with medical oncology department (1·29; 95% CI 1·02 to 1·63) were positively associated with ACCEoL. There was no association between hospital palliative care services at the hospital of death and ACCEoL.ConclusionClinical factors related to a better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and gastrointestinal malignancies might represent groups with complex needs, and haematological patients may be at increased risk because of unpredictable prognosis. Improvement of hospital palliative care services could help reduce ACCEoL, particularly in cancer centres and hospitals with medical oncology department, as those services are usually under-resourced, thus reaching few.

Assessment of potential process quality indicators for systemic treatment of breast cancer in Belgium: a population-based study

“…As for the administration of intravenous chemotherapy during the last 2 weeks of life, the results in our cohort (5.4%) appeared reasonable and comparable with other European data. 30 Besides, no significant variability was observed between treatment centres in Belgium.…”

Chemotherapy at the End of Life – The Reality of an Oncological Centre

“…The use of chemotherapy at end-of-life, particularly in the last month, is considered an aggressive measure and should be avoided [5]. One of the largest studies in Portugal to assess the factors associated with the aggressiveness of end-of-life care [6], revealed that advanced age, breast cancer and metastatic disease are associated with a lower risk of aggressiveness, while the existence of other comorbidities, gastrointestinal and hematological neoplasms were considered risk factors in this context. This study also showed that, in Portugal, 7 out of 10 patients with cancer in the end of life stage were subjected to some type of aggressiveness in the care provided, such as chemotherapy treatments in the last month of life, a higher number of hospitalization episodes and higher number of deaths in the hospital environment.…”

Ethical and Legal Issues in End-of-life Care: The Case of Life Prolongation

“…This reality of excessive use of technology has contributed to the dehumanization of health care provision, namely the use of disproportionate means of treatment and diagnosis in terminally ill patients [9]. In a retrospective study (2010-2015) involving 92,155 cancer patients in hospital units in Portugal published in 2020 in the journal European Society for Medical Oncology Open, the authors reported a 71% prevalence of aggressive end-of-life care [10].…”

“…In this line of thought, we believe it is pertinent to reflect on a subject that, in our opinion, is somewhat hidden, but which is relevant in bioethics: dysthanasia. We believe that more than the discussion on euthanasia that has overflowed in recent years into the newspaper headlines, the practice of using all diagnostic/therapeutic means available to prolong lives by a thread, postponing death, is an act still very present in hospitals [9][10][11][12][13][14]. Despite this evidence, this debate "…has in large part been neglected, not only in treatment decisions at the bedside but in public discussions-comfort care-the physician's obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life" [15].…”