Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital

Abstract

BackgroundDecisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT.MethodsThis prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form.ResultsOverall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia.ConclusionOur results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.

Elements for assistance to patients with hematological malignancies to propose care lines: a scoping review

“…However, the mortality rate for hematological malignancies is still high ( 7 , 43 - 44 ) . Thus, palliative care aims to improve care during the final life trajectory and should be integrated in a timely manner in standard oncological care.…”

Elementos para assistência a pacientes com neoplasias hematológicas para propor linhas de cuidado: scoping review

“…Contudo, a taxa de mortalidade para as neoplasias hematológicas ainda é elevada (7,(43)(44) . Desse modo, os cuidados paliativos têm a finalidade de melhorar o cuidado durante a trajetória final de vida e devem ser integrados em tempo hábil no cuidado oncológico padrão.…”

Behandlung im Voraus Planen – ein Praxisprojekt zur Implementierung vorausschauender Versorgungsplanung in einer onkologischen Abteilung

“…Die Sinnhaftigkeit frühzeitiger BVP ist weitestgehend akzeptiert [1,3]. Demgegenüber gibt es über den Einsatz von BVP in der Onkologie in Deutschland bislang wenig dokumentierte Er-fahrung.…”

“…Internationale Erkenntnisse weisen auch darauf hin, dass der Gemütszustand von Patient*innen durch den BVP-Prozess günstig beeinflusst wird und es häufiger zum Einsatz von an der Präferenz orientierten Therapiemaßnahmen kommt, einhergehend mit einer höheren Lebensqualität [2]. In Deutschland hat der Gesetzgeber mit dem § 132 g (SGB V) die Rahmenbedingungen für BVP für Senior*innen in Pflegeheimen und für Menschen mit Behinderungen in Einrichtungen der Eingliederungshilfe eingeführt [1][2][3]; Krankenhäuser sind in dieser Regelung bisher (noch) nicht berücksichtigt.…”