Most doctors delay end-of-life talks with terminal patients who feel well

Despite guidelines recommending that physicians discuss end-of-life options with terminally ill patients, most who see cancer patients would not do so as long as their patients are feeling well, according to a nationwide survey. Physicians instead wait for symptoms to develop or until there are no more treatments to offer.

Guidelines from the National Comprehensive Cancer Network and National Consensus Project for Quality Palliative Care recommend discussing end-of-life issues for terminally ill patients with less than one year of life expectancy. Talks should review prognosis; set advanced directives; and review options for “do not resuscitate,” palliative care including hospice, and preferred site of death.

Researchers presented a national sample of 4,074 physicians with a scenario of a patient newly diagnosed with metastatic cancer who is currently feeling well but has four to six months to live. They were then asked when they'd discuss prognosis, do-not-resuscitate orders, palliative/hospice care and preferred site of death. Options were “now,” “when the patient first has symptoms,” “when there are no more nonpalliative treatments,” “only if the patient is hospitalized,” and “only if the patient or family bring it up.” Results appeared in CANCER, a peer-reviewed journal of the American Cancer Society.

While 65% of physicians would discuss prognosis “now,” fewer would discuss patients' preferences for resuscitation (44%), hospice (26%), or where patients would like to die (21%). Instead, most would wait until patients felt worse or until no more treatment options were available.

The survey also found that younger physicians would discuss end-of-life options sooner than older doctors (P=0.008) and that physicians who were not cancer specialists would discuss them sooner than cancer specialists (P<0.001). Female physicians were less likely to discuss prognosis right away (P=0.05). Office-based doctors were more likely to discuss hospice options than their hospital-based peers (P=0.007). Physicians caring for patients in HMO or VA settings were also more likely to start these discussions earlier than physicians who cared for patients in other settings.