Reply to Physicians and end-of-life issues


  • Nancy L. Keating MD, MPH,

    1. Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital; Massachusetts
    2. Department of Health Care Policy Harvard Medical School Boston, Massachusetts
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  • Katherine L. Kahn MD

    1. RAND Santa Monica, California
    2. Division of General Internal Medicine Department of Medicine University of California at Los Angeles Los Angeles, California
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We appreciate Dr. Gozetti's interest in our article.1 We agree entirely that patients' preferences are incredibly important throughout the entire spectrum of their cancer experience, including the end of life. Because our study included only data from physicians, the focus of the article was on physicians rather than patients.

Dr. Gozzetti suggests that he does not necessarily agree with the US guidelines that recommend advance care planning for terminally ill patients. Many physicians in our cohort appear to share his view, because most reported not discussing end-of-life issues with an asymptomatic terminally ill patient with a prognosis of 4 to 6 months. We agree that not all patients want to know everything and/or discuss these issues immediately. Nevertheless, many patients may, and those who do may be reluctant to initiate these discussions. Thus, we believe that it is important for physicians to do so.

Dr. Gozzetti suggests that he does not discuss do not resuscitate (DNR) status with patients who have no chance of recovery. In the United States, the Patient Determination Act of 1990,2 which required hospitals to inform patients about their medical decision-making rights (including the right to refuse life-sustaining care such as cardiopulmonary resuscitation), has been interpreted such that all patients have a right to cardiopulmonary resuscitation unless there is a DNR order in place. Thus, DNR discussions are important, and these may be best initiated by a physician who knows a patient well. When patients are feeling well, they may be better able to discuss their wishes with their physicians and family members. In this way, discussions regarding end of life provide a mechanism for the patient's voice to be heard. Often in the United States, patients have not had DNR discussions before becoming too ill to make decisions. Evidence suggests that earlier end-of-life discussions, including discussions concerning DNR status, are associated with less ventilation and resuscitation near death, which in turn is associated with better patient quality of life and caregiver bereavement adjustment.3


This work of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (Dana Farber Cancer Institute/Cancer Research Network [U01 CA093332], Harvard Medical School/Northern California Cancer Center [U01 CA093324], RAND/UCLA [U01 CA093348], University of Alabama at Birmingham [U01 CA093329], University of Iowa [U01 CA01013], and University of North Carolina [U01 CA093326]) and by a Department of Veterans Affairs Health Services Research and Development Service grant (CRS 02-164) to the Durham Veterans Affairs Medical Center.