Influence of patients' preferences and treatment site on cancer patients' end-of-life care

Authors

  • Alexi A. Wright MD,

    Corresponding author
    1. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    3. Harvard Medical School, Boston, Massachusetts
    4. Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    • Department of Medical Oncology and Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Smith 333, 44 Binney Street, Boston, MA 02115
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    • Fax: (617) 632-3479

  • Jennifer W. Mack MD, MPH,

    1. Harvard Medical School, Boston, Massachusetts
    2. Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    3. Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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  • Patricia A. Kritek MD, EdM,

    1. Harvard Medical School, Boston, Massachusetts
    2. Combined Program in Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
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  • Tracy A. Balboni MD, MPH,

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Harvard Medical School, Boston, Massachusetts
    3. Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    4. Dana-Farber Cancer Institute Department of Radiation Oncology, Boston, Massachusetts
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  • Anthony F. Massaro MD,

    1. Harvard Medical School, Boston, Massachusetts
    2. Combined Program in Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
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  • Ursula A. Matulonis MD,

    1. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Harvard Medical School, Boston, Massachusetts
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  • Susan D. Block MD,

    1. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Harvard Medical School, Boston, Massachusetts
    3. Harvard Medical School Center for Palliative Care, Boston, Massachusetts
    4. Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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  • Holly G. Prigerson PhD

    1. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
    2. Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    3. Harvard Medical School, Boston, Massachusetts
    4. Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
    5. Harvard Medical School Center for Palliative Care, Boston, Massachusetts
    6. Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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  • Drs. Prigerson and Wright had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of data analysis. Drs. Wright and Prigerson were responsible for the study design and conception; Dr. Prigerson obtained funding for the study and was responsible for data acquisition; Drs. Wright, Mack, Kritek, Balboni, Massaro, Matulonis, Prigerson, and Block analyzed and interpreted the data; Dr. Wright conducted statistical analyses and drafted the article; and Drs. Wright, Mack, Kritek, Balboni, Massaro, Matulonis, Prigerson, and Block critically revised the article for important intellectual content.

Abstract

BACKGROUND:

Research suggests that patients' end-of-life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life-extending therapy was associated with their EOL care.

METHODS:

Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life.

RESULTS:

Eighty-three of 301 patients (27.6%) with advanced cancer wanted life-extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life-extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P ≤ .003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.16-8.47) and less hospice services (OR, 0.52; 95% CI, 0.29-0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life-extending care were more likely to receive intensive care (adjusted OR [AOR], 2.91; 95% CI, 1.09-7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26-0.78). Treatment site was not identified as a significant predictor of EOL care.

CONCLUSIONS:

The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care. Cancer 2010. © 2010 American Cancer Society.

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