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Quality of Life Better for Cancer Patients with Less Medical Care at the End

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Cancer-patientsQuality of Life Better for Terminal Cancer Patients with Less Care at the End

Dying in the hospital and intensive care unit admissions in the last week of life accounted for the greatest negative variance in quality of life for terminal cancer patients according to a prospective, longitudinal cohort study published in the Archives of Internal Medicine

Patients dying of cancer have a better quality of life towards the end if aggressive, life-prolonging measures are avoided and if they are able to die at home, a multicenter study suggested.

Being admitted to the intensive care unit during the last week of life was the strongest negative factor, accounting for −4.4% of variance in patients' quality of life, according to Holly G. Prigerson, PhD, and colleagues from Harvard University in Boston.

Improving Quality of Life for Cancer Patients

Factors that contributed to greater quality of life included patients' self-reported participation in prayer and in-hospital pastoral care, as well as self-reported therapeutic alliances with their physicians.

Also strongly influential was in-hospital death, the researchers reported online in Archives of Internal Medicine.

Although some earlier research has focused on general aspects of end-of-life care, such as pain management and physician responsiveness, the specific factors that matter most to patients with terminal cancer and their families have not been fully explored, the researchers said.

"The concept of quality of the [end of life] in cancer patients has been underexamined in cancer medicine in the quest to develop newer, more advanced, and effective modalities of interventional cytotoxic therapies," wrote Alan B. Zonderman, PhD, and Michele K. Evans, MD, of the National Institute on Aging in Baltimore, in an invited commentary.

To this end, a prospective study termed Coping With Cancer has been examining the concerns of a wide variety of patients and their caregivers, who were interviewed at baseline about sociodemographic factors, physical and psychological status, treatment preferences, and support structures.

After the patient's death, caregivers were asked about end-of-life treatments, location of the death, and physical and psychological distress during the final week.

Most of the 396 patients in the study were white (65%), belonged to a Christian religion (71.3%), and had health insurance (60.8%).

Mean age was 58.7 years, and median survival after enrollment was about 4 months.

In unadjusted analyses, factors that predicted worse quality of life included major depression, panic disorder, and a high degree of worry, while "a sense of inner peacefulness" at baseline was associated with better quality of life at the end.

The researchers then conducted a series of complex analyses involving random effects modeling and cross-validation to determine a final model with the lowest mean squared error.

In this best-fitting model, these factors were baseline predictors and had the following parameter estimates:

  • Pastoral care in the hospital or clinic, 1.60 (P=0.052)
  • Therapeutic alliance with physician, 1.45 (P=0.09)
  • Intensive care unit stay, −5.61 (P<0.001)
  • Death in the hospital, −3.03 (P=0.003)
  • Religious activities prior to cancer diagnosis, 0.66 (P=0.005)
  • Worry or anxiousness, −0.39 (P=0.002)
  • Chemotherapy during the last week of life, −3.46 (P=0.04)
  • Feeding tube during the last week of life, −3.54 (P=0.03)

Then, in the analysis considering the variance in quality of life, the researchers determined that, aside from intensive care stay and in-hospital death, factors that explained quality of life variance in a negative fashion were patient worry (−2.7%), feeding tube placement in the final week (−1.1%), and chemotherapy in the final week (−0.8%).

The researchers noted that alleviating patient anxiety and worry is potentially modifiable and should be a priority among caregivers and clinicians.

Factors influencing variance in quality of life in a positive fashion were prayer or meditation (2.5%), site of care (1.8%), pastoral care (1%), and therapeutic alliance (0.7%).

The therapeutic alliance between patient and physician was a less strongly influential predictor than the other factors, but should still be considered important, according to the researchers.

"Physicians who are able to remain engaged and 'present' for their dying patients -- by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings -- have the capacity to improve a dying patient's [quality of life]," Prigerson and colleagues stated.

In their commentary, Zonderman and Evans also called for more research into patient characteristics before they become ill.

"This is important because dispositions and personality characteristics are related to self-rated [quality of life], particularly optimism," they wrote.

Prigerson and colleagues agreed that more research is needed, because even in their best model, the factors they identified accounted for less than 20% of the variance in quality of life, "leaving much to learn about other influences on this outcome."

The study was supported by the National Institute of Mental Health, the National Cancer Institute, and Dana-Farber Cancer Institute.

The authors reported no financial disclosures.

Zhang B, et al "Factors important to patients' quality of life at the end of life" Arch Intern Med 2012; doi:10.1001/archinternmed.2012.2364.

Zonderman A, Evans M "Improving patients' quality of life at the end of life" Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3169.

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