Possible Underestimation of the Provision of Palliative Care

Abstract

In Reply We appreciate Conner and colleagues for their interest in our article, 1 as well as their thoughtful comments. The authors raise 2 important questions: (1) is aggressive care truly discordant with patient wishes, and (2) do these data, when not placed in larger context, contribute to an "institutionalization of quitting?"In addressing the first argument, we would like to highlight a commonly encountered debate when discussing endof-life care-the issue of timing. This study was carefully limited to the last 30 days of life to distinguish between aggressive cancer care and aggressive end-of-life care. There is no doubt that tremendous, life-prolonging advancements have been made for patients with brain tumors, especially brain metastases. This study does not contest the utility of appropriately aggressive cancer treatment early in the disease course.However, most would agree that in the last 30 days of life, these treatments are of limited efficacy. Indeed, only a small proportion of patients receive cancer-directed treatment during this period. 2 Hospital-based care, at least in the context of our study, is most likely directed at managing symptoms related to terminal disease progression rather than attempts to provide a cure. This supports the authors' opening sentiment that physicians generally are not "going for broke" with heroic measures. Regardless, the primary costs of concern to us were not financial-nor should they ever be. 3 Our data ask that we all carefully consider why these patients so often require hospitalization immediately preceding death.An admitted bias of our study is that the last 30 days of life is much easier to define in retrospect than in real time. Our data concur with Conner and colleagues that physicians are poor at accurately predicting prognostic milestones such as living 30 days. 4 In fact, this is one of the strongest arguments for early integration of palliative care.The authors also raise the question of whether this study promotes the idea of "quitting" on older patients with cancer and ask that the data be put into context. The primary purpose of our analysis was to provide quantitative data to help create such context for future studies. To have any informed debate on appropriate end-of-life care, we need to better understand the current status of the delivery of care in this setting.This study is by no means meant to institutionalize quitting. Rather, we hope our data will help to deinstitutionalize the erroneous idea that palliative care is equated with quitting. Cancer care and palliative care are not mutually exclusive. On the contrary, there is mounting evidence that early integration of palliative care into routine cancer care actually improves quality of life and possibly even survival. 5 As our understanding of the mechanism of disease and treatment of cancer evolves, so too must our understanding of patients' wishes and how they are influenced by the language we use. 6 Getting past the idea of quitting will improve both the quality and effectiveness of end-of...

What Do We Mean By “Palliative” or “Oncologic Care”? Conceptual Clarity Is Needed for Sound Research and Good Care

“…Importantly, the care received where no intervention took place warrants a more detailed description because supportive or palliative care interventions may be given (although partly unconsciously) as well during standard oncologic care. 8 Second, we believe the analysis provided by El-Jawahri et al 1 is valuable also for reflecting on health care professionals' expertise and competences within palliative and oncological care services. In this respect, we agree with the authors' notion that it is difficult to define a clear transition between the curative and palliative disease phase.…”