Odejide OO, Cronin AM, Condron N, Earle CC, Wolfe J, Abel GA. Timeliness of End-of-Life Discussions for Blood CancersA National Survey of Hematologic Oncologists. JAMA Intern Med. 2016;176(2):263-265. doi:10.1001/jamainternmed.2015.6599
Existing studies suggest a quality gap with respect to end-of-life (EOL) care for patients with blood cancers,1 and less timely EOL discussions may be partly to blame. Indeed, patients with blood cancers are more likely to receive chemotherapy and be hospitalized when near death, to die in acute care settings, and are less likely to use hospice services than those with advanced solid tumors.1 A rigorous understanding of when EOL discussions occur for patients with hematologic cancers is a necessary step toward developing targeted interventions to improve the quality of their EOL care.
From September 16, 2014, through January 21, 2015, we conducted a postal survey of US hematologists who provide direct care for adult patients with hematologic cancers, whom we identified from the clinical directory of the American Society of Hematology. We developed the survey instrument through a synthesis of preliminary data from a series of focus groups with hematologic oncologists,2 a review of the relevant literature, previously published survey instruments,3- 5 and formal cognitive debriefing.
To assess the timing of EOL discussions, we asked, “In your experience, end-of-life care discussions with patients who have hematologic cancers typically occur...,” with the response options of “too early,” “at the right time,” or “too late.”3 In addition, we examined the timing of initial conversations about specific aspects of EOL care by asking, “For patients with life-threatening hematologic cancers, when do you typically conduct the initial discussion specifically addressing resuscitation status?,” with the response options of “upon presentation or diagnosis,” “during a period of stability,” “upon disease progression,” “during an acute hospitalization,” and “when death is clearly imminent.”3 The same stem and responses were used to ask about initial discussions regarding hospice care and preferred site of death.
This study was approved by the Dana-Farber/Harvard Cancer Center Institutional Review Board.
Of the 609 eligible hematologic oncologists, 349 (57.3%) completed the survey. Their median age was 52 years, and 75.4% were men. Overall, 42.9% of the hematologists who completed the survey practiced primarily in tertiary centers and 55.4% practiced in community centers. Of the 345 individuals who answered the question about typical timing of EOL discussions, 55.9% reported that, in their experience, these discussions occur “too late.” Respondents in tertiary centers were more likely to report late EOL discussions than were those in community centers (64.9% vs 48.7%, P = .003) (Table 1), an association that remained significant in multivariable analysis. As for specific topics of EOL care, 42.5% of the respondents reported conducting their first conversation about resuscitation status at less optimal times; 23.2% and 39.9%, respectively, reported that they typically wait until death is clearly imminent before conducting an initial conversation about hospice care or preferred site of death (Table 2). Moreover, hematologic oncologists at tertiary centers were less likely to initiate hospice and resuscitation status discussions at more optimal times than were those at community centers.
Several factors may contribute to untimely EOL discussions in hematologic oncology. First, unlike most solid malignant neoplasms, which are incurable when they reach an advanced stage (stage IV), many advanced hematologic cancers remain potentially curable. This lack of a clear distinction between the curative and EOL phase of disease for many hematologic cancers may delay the initiation of appropriate EOL discussions.2 Second, physicians may hesitate to conduct EOL discussions because of fear of affecting patients’ emotional coping capacity and hope6 or because physicians themselves find it difficult to “give up” on patients they might potentially have cured.
Moreover, although tertiary settings often have greater availability of EOL resources and/or offer academic departments of palliative care, hematologic oncologists in these settings were more likely to report late EOL discussions. They were also less likely to initiate conversations about resuscitation status or hospice care at more optimal times. These findings suggest the need for physician-targeted interventions for improving the timeliness of EOL discussions, especially for patients with hematologic cancers treated in tertiary settings.
Corresponding Author: Oreofe O. Odejide, MD, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 (firstname.lastname@example.org).
Published Online: December 21, 2015. doi:10.1001/jamainternmed.2015.6599.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was supported by a postdoctoral fellow award from the Lymphoma Research Foundation (Dr Odejide) and a Young Investigator Award from the Conquer Cancer Foundation (Dr Odejide).
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.