The authors say patients with cancer and dementia were more likely to have palliative care consultations and DNR orders.
A recent study in JAMA Internal Medicine found that families report the quality of end-of-life care to be significantly better for patients with cancer and dementia than for patients with end stage renal disease (ESRD), congestive heart failure, chronic obstructive pulmonary disease (COPD), or frailty. The researchers attributed the difference to the fact that because cancer and dementia patients had higher rates of palliative care consultation and do-not-resuscitate (DNR) orders and fewer deaths in the intensive care unit (ICU) than patients suffering from other serious illnesses. Death in the ICU is associated with worse family-reported quality of care.
“While there is room for improvement in the quality of end-of-life care for all patients, it is particularly true for patients dying of heart failure, chronic lung disease, and renal failure,” concluded lead researcher Melissa W. Wachterman, MD, MSc, MPH, assistant professor of medicine at Harvard Medical School and a physician both in the Department of Psychosocial Oncology and Palliative Care at Dana-Farber/Brigham and Women’s Cancer Center and the VA Boston Healthcare system.
The study analyzed medical records and family surveys for over 34,000 patients at 146 inpatient Veterans Affairs (VA) health system facilities who died between 2009 and 2012. Diagnosis was significantly associated with the proportion of veterans who received palliative care consultations (cancer, 74%; dementia, 61%; ESRD, 50%; cardiopulmonary failure, 47%; and frailty, 44%), and who, according to next of kin, received excellent care (cancer, 59%; dementia, 59%; ESRD, 55%; cardiopulmonary failure, 55%; and frailty, 54%). Patients with ESRD, congestive heart failure, COPD, or frailty were far less likely to receive palliative care consultations than patients with cancer or dementia. Approximately a third of these patients died in the ICU, more than double the rate for those with cancer or dementia. They were also less likely to have DNR orders.
Patients who had a palliative care physician received better end-of-life care, the families reported. The researchers concluded that increased access to palliative care at the end of life may improve end-of-life care for those with heart, lung, and kidney diseases. An rising number of older Americans are dying of these conditions, Wachterman noted. Healthcare providers and policymakers need to pay special attention to improving end-of-life care for patients with ESRD, cardiopulmonary failure, and frailty, the investigators recommend.
Another important finding was the high prevalence of pain among these inpatients who died. More than three-quarters of patients had pain in the last month of life, and more than half had frequent, uncontrolled pain. The finding that patients with ESRD and frailty had rates of frequent, uncontrolled pain similar to those of patients with cancer suggests another opportunity to improve care, the researchers note.
The study’s results were also presented at AcademyHealth’s Annual Research Meeting in Boston on June 27, 2016.
Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses [published online June 26, 2016]. JAMA Intern Med. 2016; doi:10.1001/jamainternmed.2016.1200