Advanced care planning is an act of love
Based on a single well-done randomized controlled trial (RCT). Recommend a palliative care consultation at the time of diagnosis. Early palliative care can improve quality of life, decrease depressive symptoms, and prolong life in patients with metastatic cancer.
First, patients are more likely to choose symptom-directed care when they understand they are terminally ill. Second, patients whose physicians engage them in conversation about their wishes for EOL care are more likely to receive care consistent with their preferences. And finally, the majority of the patients who receive life-extending measures have previously expressed a desire to receive symptom-directed care.
Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol. 2010 Mar 1;28(7):1203-8. doi: 10.1200/JCO.2009.25.4672. Epub 2010 Feb 1. PMID: 20124172; PMCID: PMC2834470.
EOL discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient QoL and worse bereavement adjustment.
Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL, Jackson VA, Block SD, Maciejewski PK, Prigerson HG. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008 Oct 8;300(14):1665-73. doi: 10.1001/jama.300.14.1665. PMID: 18840840; PMCID: PMC2853806.
Early palliative care was associated with improved end-of-life outcomes. Late initiations were associated with greater acute-care use, with the largest influence on organ failure and frailty decedents, suggesting potential opportunities for improvement.
Qureshi D, Tanuseputro P, Perez R, Pond GR, Seow HY. Early initiation of palliative care is associated with reduced late-life acute-hospital use: A population-based retrospective cohort study. Palliat Med. 2019 Feb;33(2):150-159. doi: 10.1177/0269216318815794. Epub 2018 Dec 3. PMID: 30501459; PMCID: PMC6399729.
One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Duration of palliative care is much shorter than the 3–4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics.
Jordan, R.I., Allsop, M.J., ElMokhallalati, Y. et al. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med 18, 368 (2020). https://doi.org/10.1186/s12916-020-01829-x
Cancer decedents who received palliative care earlier than 6 months before death compared with those who did not had a lower absolute risk difference of receiving hospital care and dying in hospital, and an increased absolute risk difference of receiving supportive home care in the last month of life.
Seow H, Sutradhar R, Burge F, et al End-of-life outcomes with or without early palliative care: a propensity score matched, population-based cancer cohort study BMJ Open 2021;11:e041432. doi:10.1136/bmjopen-2020-041432
Byock, I. (1997). Dying Well: Peace and Possibilities at the End of Life. New York, NY: Riverhead Books.
Fersko-Weiss, H. (2020). Finding Peace at the End of Life: A Guide for Patients and Their Families. Newburyport, MA: Red Wheel.
Gawande, A. (2014). Being Mortal: Medicine and What Matters in the End. Toronto, ON: Anchor Canada.
Green, S. (2022). This is Assisted Dying: A Doctor's Story of Empowering Patients at the End of Life. New York, NY: Scribner.
Jenkinson, S. (2015). Die Wise: A Manifesto for Sanity and Soul. Berkeley, CA: North Atlantic Books.
Kessler, D. (2007). The Needs of the Dying: A Guide for Bringing Hope, Comfort, and Love to Life’s Final Chapter. New York, NY: HarperCollins Publishers.
Mingyur Rinpoche. (2019). In Love with the World: A Monk's Journey Through the Bardos of Living and Dying. New York, NY: Penguin Random House.
Ostaseski, F. (2017). The Five Invitations: Discovering What Death Can Teach Us About Living Fully. New York, NY: Flatiron Books.
Zitter, J. N. (2017). Extreme Measures: Finding a Better Path to the End of Life. New York, NY: Avery.