Background:

The majority of patients with serious illness die in an acute care hospital. The dying process is often filled with clinically and ethically challenging decisions. Frequently, patient care at the end of life is focused on life‐sustaining treatments, whereas patient comfort, dignity, and suffering are not a primary focus. End‐of‐life discussions may clarify treatment options and shift the emphasis from cure to palliation. Among cancer patients, end‐of‐life discussions can reduce the use of life‐sustaining treatments, CPR, and ICU admission while enhancing quality of life at the end of life. We examined patients with advanced cancer who died in the hospital. Our questions were: (1) What proportion of these patients had decisional capacity at the time of a terminal hospital admission? (2) Among those with decisional capacity on admission, was medical record documentation of a discussion about end‐of‐life care associated with life‐sustaining and palliative treatments received?

Methods:

This was a retrospective chart review of consecutive patients with the following criteria: (1) age > 18 years at time of cancer diagnosis, (2) estimated 5‐year survival < 20% at time of cancer diagnosis, (3) entirety of cancer treatment conducted at the university hospital, and (4) died during the target hospitalization. We also identified patients who had intact decisional capacity on admission. We examined all eligible patients hospitalized from January 1, 2004, to December 31, 2007. Charts were reviewed by an internist using a 47‐item chart abstraction tool. Outcomes included life‐sustaining and palliative treatments received.

Results:

A total of 145 patients met inclusion criteria, and 103 of these patients (71%) had decisional capacity at the time of admission. The leading cancer diagnoses were lung (n = 42), acute myelogenous leukemia (n = 29), esophagus (n = 9), and pancreas (n = 6). Of the patients with decisional capacity on admission, 57 (55.3%) participated and 46 (44.7%) did not participate in a discussion about end‐of‐life care with their providers, as documented in the medical record. Patients who did not participate in these conversations were more likely to receive invasive mechanical ventilation (56.5% vs. 22.8%, P < 0.01) and to receive chemotherapy (39.1% vs. 5.3%, P < 0.01) compared with those patients who did participate in a discussion. There was no statistically significant difference between groups in the use of comfort care or palliative medicines such as morphine.

Conclusions:

Most patients with advanced cancer have decisional capacity at the time of a terminal hospitalization. In these patients, a discussion about end‐of‐life care is associated with decreased use of invasive life‐sustaining treatments. Our results suggest that it is important to seize the opportunity to involve hospitalized terminal cancer patients in discussions about end‐of‐life care, as such discussions are associated with lower use of invasive treatment.

Disclosures:

M. Zaros ‐ none