Terminal cancer patients who receive chemotherapy in the last months of their lives are less likely to die where they want and are more likely to undergo invasive medical procedures than those who do not receive chemotherapy, according to a study.
The findings underscore a disconnect between the type of care many cancer patients say they want and the kind they receive, and highlight the need for clearer and more balanced discussion of the harms and benefits of palliative chemotherapy at the end of life by doctors, patients and families, the study authors said. The study was published in BMJ.
Whereas 80 percent of patients who did not receive palliative chemotherapy died where they wished, only 68 percent of those whose disease management included palliative chemotherapy died in the place they wanted to. Nearly 66 percent of patients who did not receive palliative chemotherapy died at home, compared to 47 percent of patients who received palliative chemotherapy. Patients who received palliative chemotherapy were much more likely than their counterparts to die in an intensive-care unit, a contrast of 11 to 2 percent.
The reasons for the link may originate in patients’ misunderstanding of the purpose and likely consequences of palliative chemotherapy and lack of acknowledgment of their own prognoses, said researchers.
In the study, patients getting palliative chemotherapy were less likely to talk to their oncologists about the care they wanted to receive if they were dying, to complete Do-Not-Resuscitate orders, or to acknowledge they were terminally ill.
With 56 percent of patients receiving palliative chemotherapy in their final months, the findings underscore the potential harms of aggressive use of chemotherapy in dying patients, and the possible need for widespread changes in oncology practice at academic medical centers.
Researchers analyzed data from 386 patients in the federally funded Coping with Cancer study, which followed terminally ill people and their caregivers until after the patients died. During the six-year study, researchers examined how psychosocial factors influenced patients’ care. In the month after the patients died, caregivers were asked to rate their loved ones’ care, quality of life, and place of death as being where the patient would have wanted to die. The investigators then reviewed patients’ medical charts to determine the type of care they actually received in their last week.
Even after the researchers took into account characteristics such as age, marital status, whether a patient had health insurance, their overall physical and mental health, and the treatment they preferred, those who received palliative chemotherapy still underwent more invasive medical procedures in the last week of their lives and in more cases died in ICUs than patients who did not receive palliative chemotherapy. Among those interventions were CPR and mechanical ventilation.
Patients who received palliative chemotherapy were also more likely to be referred to hospice care, which provides comfort care and emotional support, a week or less before they died. Some 54 percent of patients receiving palliative chemotherapy were referred to hospice late, compared to about 37 percent of patients who weren’t taking the drugs.
However, researchers said, the results should not be taken to mean that patients should be denied or not offered palliative chemotherapy.
