Precious Time: Questionable Treatments Often Used at the End of Life

When older patients are hospitalized near the end of life, uncertainty about their preferences for treatment, about prognosis, and about the usefulness of various therapies for advanced stages of disease creates an environment in which nonbeneficial treatments are widely used, as illustrated by a systematic review of studies conducted around the world.

On average, 33% to 38% of patients admitted with advanced chronic illnesses—including heart failure and others—received treatments deemed to carry little or no chance of having a positive effect in the last 6 months of life, lead author Magnolia Cardona-Morrell, PhD (University of New South Wales, Sydney, Australia), and colleagues report in a study published online June 27, 2016, ahead of print in the International Journal for Quality in Health Care.

There are multiple reasons why these types of therapies are used so frequently, Cardona-Morrell told TCTMD. For one, advances in technology have created unrealistic expectations among patients and their families about the ability to treat certain conditions and delay death, she said. Also playing into it is the fact that many patients haven’t had conversations with family members and doctors about how they’d like to be treated at the end of life.

Doctors, who are often uncertain about a patient’s prognosis, are then left with “the dilemma between doing what they do best, which is trying to save a life, and giving the patient the right to die with dignity,” Cardona-Morrell said. From that mix of factors, the result is often the use of therapies with questionable utility in an attempt to do something for the patient.

This is a big issue, particularly for patients with advanced heart failure, according to Christopher O’Connor, MD (Inova Heart and Vascular Institute, Falls Church, VA), who was not involved in the study. He agreed that decision making can be complicated by the lack of uncertainty about prognosis and a failure to have initiated discussions about end-of-life care and advanced directives.

“A number of patients don’t have that sort of discussion early enough in the heart failure setting,” he said.

Also, he said, some therapies that have shown benefit in certain populations—like temporary assist devices or extracorporeal membrane oxygenation (ECMO)—have not been well studied in patients who are older and have a high burden of comorbidities. Nevertheless, clinicians often feel like they need to try to help a patient by using these treatments, O’Connor said.

The downsides of using these nonbeneficial treatments are many and include unnecessary costs, additional pain and discomfort for the patient, and potential complications, all of which add to the “overall turmoil in that very precious time that somebody has at the end of life,” O’Connor said, adding that not enough thought is given to administering palliative care instead.

Substantial Variation Across Studies

Cardona-Morrell and colleagues looked at data on more than 1.2 million older patients with advanced illnesses—including chronic heart failure, cancer, chronic kidney disease, chronic liver disease, stroke, and chronic obstructive pulmonary disease—from 38 studies conducted in 10 countries.

At least one-third of patients, on average, received nonbeneficial treatments in the last 6 months of life, although there was wide variation across studies. Some of the specific therapies examined were:

• Resuscitation attempts for terminal patients: 28% (ranging from 11% to 90%)
• ICU admission among incurable patients: 33% (ranging from 2% to 90%)
• Active measures, including dialysis, radiotherapy, transfusions, and life support given to terminal patients: 30% (ranging from 7% to 77%)
• Administration of antibiotics and cardiovascular, digestive, and endocrine therapies to dying patients: 38% (ranging from 11% to 75%)

“It is worth noting that some degree of these treatments is likely to be justified depending on whether the death is anticipated (known to be in the last 6 months or last year of life) or unexpected (patient in ICU in the last month or last 14 days of life),” the authors write.

The substantial variation seen across studies, however, indicates that there is an opportunity for improvement, O’Connor said.

What Can Be Done?

O’Connor said that, in order to reduce nonbeneficial treatments, “there needs to be more transparency and research and education around this issue” that can be translated into guideline changes and policy reforms.

Then, perhaps, the use of nonbeneficial treatments should be incorporated as a quality indicator to try to minimize variations, he said. Payment reform, in which compensation is adjusted according to the amount of evidence supporting various therapies, will also help, he added.

O’Connor said this issue is on the radar of major professional societies, including the American Heart Association, the American College of Cardiology, and the Heart Failure Society of America, as well as the National Institutes of Health.

“So I think we’re going to see more attention paid to this, particularly as we move into value-based healthcare, as we try to continue on the journey of providing the highest quality of care that’s evidence-based but being more sensitive to the issues around advanced directives, communication, and really careful articulation of these advanced therapies for which there’s limited evidence of benefit,” he said.

Cardona-Morrell said that both doctors and patients have roles to play in reducing use of these types of treatment. Patients should discuss end-of-life options with their relatives so that family members will not feel guilty about making important decisions on their behalf, she said.

General practitioners should review the medical records of patients they see often to set the basis for conversations about advanced directives and end-of-life care, Cardona-Morrell said. And, she added, physicians in hospitals should familiarize themselves with prognostic tools to increase their certainty about a patient’s outlook and to increase the confidence needed to propose a transition from aggressive to palliative care.

“The idea is all of us can contribute to decreasing the prevalence of nonbeneficial treatments,” Cardona-Morrell said.

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