Palliative chemotherapy may overshadow patients' wishes for end-of-life care

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 newly published research.

The findings, published in BMJ (2014;348:g1219), 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 between doctors, patients, and families, the study authors said.

The Weill Cornell Medical College, Dana-Farber Cancer Institute, and Harvard Medical School study found sobering outcomes for patients who received palliative chemotherapy, which are treatments designed to prolong survival and ease symptoms, but not to cure disease. These differences were found among patients whom physicians had determined had 6 or fewer months to live.

Eighty percent of patients who did not receive palliative chemotherapy died where they wished, whereas only 68% of those whose disease management included palliative chemotherapy died in the place they wanted to. Nearly 66% of patients who did not receive palliative chemotherapy died at home, compared with 47% 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%.

"It's hard to see in these data much of a silver lining to palliative chemotherapy for patients in the terminal stage of their cancer," said senior author Holly Prigerson, PhD, of Weill Cornell Medical College in New York, New York. "Until now, there hasn't been evidence of harmful effects of palliative chemotherapy in the last few months of life. This study is a first step in providing evidence that specifically demonstrates what negative outcomes may result. Additional studies are needed to confirm these troubling findings."

The reasons for the link are complex, but may originate in patients' misunderstanding of the purpose and likely consequences of palliative chemotherapy and lack of acknowledgment of their own prognoses, said Prigerson.

In the study, patients undergoing 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, noted Prigerson. With 56% 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.

"Our finding that patients with terminal cancers were at higher risk of receiving intensive end-of-life care if they were treated with palliative chemotherapy months earlier underscores the importance of oncologists asking patients about their end-of-life wishes," said lead author Alexi Wright, MD, MPH, of Dana-Farber Cancer Institute in Boston, Massachusetts.

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