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Wednesday, February 8, 2012

End-of-life discussions happen far too late

Most patients with stage IV lung or colorectal cancer discuss end-of-life care planning with physicians before death, but most often, the talks happen much too late.

Many end-of-life discussions occur during acute hospital care, with the median happening a month before death, researchers reported. National guidelines recommend that physicians discuss end-of-life care planning with patients with cancer whose life expectancy is less than one year.

To evaluate the incidence of end-of-life care discussions for 2,155 patients with stage IV lung or colorectal cancer, researchers designed a prospective cohort study of patients from the Cancer Outcomes Research and Surveillance Consortium (CanCORS), a group of patients diagnosed with lung or colorectal cancer from 2003 to 2005 from five large health maintenance organization insurance plans or 15 Veterans Health Administration sites in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama.

Results appeared in the Feb. 7 issue of Annals of Internal Medicine.

In the study, 73% of patients had end-of-life care discussions. Among the 1,470 patients who died during follow-up, 87% had end-of-life care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up.

For the 1,569 patients with end-of-life care discussions, topics included resuscitation (46%) and hospice care (82%). Other topics noted in medical records included palliative care (13%) and venues for dying other than hospice (3%). Of the 1,081 first end-of-life care discussions for which information was available, 55% occurred in the inpatient hospital setting.

Of the 806 first end-of-life care discussions documented in medical records for which provider type was known, participating providers included medical oncologists (49%), general medical physicians (36%), palliative care physicians (6%), other medical specialists (7%), radiation oncologists (4%), surgeons (3%), and other providers (0.5%).

Discussions with oncologists were divided evenly between inpatient and outpatient settings, but discussions with general medical physicians tended to take place in the inpatient setting (73%). Abstracted medical record data were available from visits with medical oncologists for 85% (1,823 of 2,155) of patients, with a median of 6 visits (interquartile range, 2 to 10). However, medical oncologists documented end-of-life care discussions with only 27% of their patients (493 of 1823).

"This finding suggests that acute medical deterioration, and not the diagnosis of incurable cancer, triggers physicians to talk about end-of-life care. The literature has also shown that physicians who have close long-term relationships with patients often wish to avoid end-of-life care discussions," the authors wrote. "Primary care physicians may also have important roles in end-of-life care decision making, but most discussions with general medicine physicians occurred in the inpatient setting, suggesting that these were hospital-based physicians and not those providing longitudinal primary care. Physicians involved in longitudinal care, however, may be best informed about the patient's prognosis and disease trajectory and best equipped to have meaningful discussions about the patient's values and goals."

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posted by Ryan DuBosar at 7:00 AM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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