Dying in Hospital, ICU Stays Identified as Most Important Determinants of Poor QOL at End of Life

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(ChemotherapyAdvisor) – Patients with advanced cancer have the highest quality of life at the end of life if they avoid hospitalization and the intensive care unit, worry less, pray or meditate, are visited by a pastor in the hospital/clinic, and feel a therapeutic alliance with their physicians, according to a study published online July 9 in Archives of Internal Medicine, a JAMA Network publication.

The study sought to identify the best set of predictors of quality of life of patients in their final week of life, for which a gap in data exists, reported Baohui Zhang, MS, formerly of the Dana-Farber Cancer Institute, Boston, and colleagues.

The multisite, prospective longitudinal cohort Coping With Cancer study enrolled 396 patients with advanced cancer and their informed caregivers from September 1, 2002 through February 28, 2008. Patients were followed to death, a median of 125 days after baseline. Mean age of the patients was 58.7 years; 65% were white, 71.3% were Christian, 60.8% were insured, and 52.4% had an educational level of high school.

Patients closer to death and younger patients had worse quality of life at end of life. The most variance in patient quality of life at end of life could be explained by a set of nine factors: intensive care unit stays in the final week (explained 4.4% of the variance), hospital deaths (2.7%), patient worry at baseline (2.7%), religious prayer or meditation at baseline (2.5%), cancer care (1.8%), feeding-tube use in the final week (1.1%), pastoral care within the hospital or clinic (1.0%), chemotherapy in the final week (0.8%), and patient-physician therapeutic alliance at baseline (0.7%), in which the patient reported being treated as a “whole person.” The vast majority of the variance in quality of life at end of life, however, remained unexplained.

The authors concluded that “By reducing patient worry, encouraging contemplation, integrating pastoral care within medical care, fostering a therapeutic alliance between patient and physician that enables patients to feel dignified, and preventing unnecessary hospitalizations and receipt of life-prolonging care, physicians can enable their patients to live their last days with the highest possible level of comfort and care.”

An invited commentary stated, “It is surprising at this stage in the development and implementation of complex multimodal cancer treatment strategies that the factors most critical in influencing the quality of the EOL [end of life] are not clearly defined and considered along the entire timeline beginning with cancer diagnosis,” they continue. “This work, as well as the American Society of Clinical Oncology statement, support early introduction of palliative care for advanced cancer patients.”

Abstract

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