Patients’ wishes regarding goals of care should be assessed frequently, similar to assessments for distress, to ensure patients’ wishes are understood and followed at the end of life (EOL). Use of a single-item visual analog scale (VAS) was found to identify patients’ goals of care throughout their cancer trajectory and help oncologists to better understand their patients’ goals of care at the end of life, according to a study published in Supportive Care in Cancer.
Understanding the wishes of patients with advanced cancer regarding EOL care is considered a measure of quality care; however, patients often receive more aggressive treatment than is supported by their goals of care. This can occur when oncologists’ perceptions of their patient’s wishes do not match the patient’s actual wishes. A study was conducted to determine the influence of patient–oncologist agreement regarding goals of care for patients with advanced cancer.
For the study, researchers identified 524 eligible patients, 378 of whom consented to participate. Oncologists enrolled in the study were the primary oncologist for the patients who had agreed to participate. Eleven oncologists were eligible, and all agreed to participate. The outcome measured was whether aggressiveness of care at EOL matched patients’ wishes for goals of care.
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The decision to use a single-item VAS was based on research that demonstrated that the modality offered a lower risk of bias from confounding factors, avoidance of the ceiling effect, and the survey could be completed more quickly than one using Likert-scaled items.
The question for patients was, “Regarding your care, what is most important to you right now?” For oncologists, the question was, “Regarding the care of this patient, what do you think is most important to the patient right now?” Responses were on a scale of 0 to 100, with 0 indicating “quality of life is all that matters” (ie, the goal of care was for comfort) and 100 indicating “length of life is all that matters” (ie, the goal of care was for survival).
Strong agreement was defined as goal of care scores from the patient and the oncologist being closely aligned. For example, with survival strong goal of care agreement indicated when both patient and oncologist responses were between 70 and 100. For comfort, strong goal of care agreement was indicated when both responses were between 0 and 30.
Aggressiveness of care was scored with a composite aggressiveness index based on previously established indices of aggressiveness of care in the last 30 days of life. These indices included more than 1 emergency department visit, more than 1 hospitalization, any intensive care unit admission, new chemotherapy, any chemotherapy in the last 14 days of life, and less than 3 days’ stay at hospice. The index was calculated as a score of 1 point for each of the 6 indices, for a total score of 0 to 6. Higher scores indicated more aggressive treatment at the end of life.
Patients and oncologists were surveyed every 3 months for the 15 months of the study, surveys ended early if the patient died or was transferred to hospice. Of the patients who agreed to participate, 206 patients died during the study period. Within the study, 72.3% of patients were white, the average patient age was 64.1 years, 51.0% of patients were female, and 75.2% of patients had a new diagnosis of cancer. More than half (53.5%) of patients included in the study used palliative care services during the study period and 63.4% had an advance directive.
At the last interview before death, 23.3% of the studied patient–oncologist dyads had strong goal of care agreement for survival (8.3%) or comfort (15%).
However, 76.7% of the dyads did not have strong agreement regarding goals of care. Goal of care scores differed by 50 points or more in 11 (7.1%) dyads in which the patient scored survival higher than the oncologist and in 21 (13.5%) dyads in which the oncologist scored survival higher than the patient.
Composite aggressiveness index showed that 53.4% of patients did not receive any aggressive care. Use of aggressive care was associated with strong agreement between patient and oncologist regarding goals of care by category. Use of at least 1 aggressive treatment was used in 64.7% of dyads with strong agreement for goals of care for survival, 29% in dyads with strong agreement for comfort, and 34.2% in dyads with no strong agreement.
“Given the relationship between dyadic concordance and use of aggressive care at EOL and the large number of dyads with no concordance regarding goals of care, it is recommended that patients’ goals of care be measured early and often,” the authors concluded.
Reference
Douglas SL, Daly BJ, Lipson AR, Blackstone E. Association between strong patient-oncologist agreement regarding goals of care and aggressive care at end-of-life for patients with advanced cancer [published online February 6, 2020]. Support Care Cancer. doi: 10.1007/s00520-020-05352-w
This article originally appeared on Oncology Nurse Advisor
