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JCO Early Release, published online ahead of print Nov 13 2012
Journal of Clinical Oncology, 10.1200/JCO.2012.43.6055

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Palliative and Supportive Care

Submitted April 12, 2012; accepted August 27, 2012.

Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study

Jennifer W. Mack, Angel Cronin, Nancy L. Keating, Nathan Taback, Haiden A. Huskamp, Jennifer L. Malin, Craig C. Earle, Jane C. Weeks

Jennifer W. Mack, Angel Cronin, Nathan Taback, and Jane C. Weeks, Dana-Farber Cancer Institute; Jennifer W. Mack, Boston Children’s Hospital; Nancy L. Keating and Haiden A. Huskamp, Harvard Medical School; Nancy L. Keating, Brigham and Women’s Hospital, Boston, MA; Jennifer L. Malin, Greater Los Angeles Veterans Administration Health Care System and University of California at Los Angeles, Los Angeles, CA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada.

Corresponding author: Jennifer W. Mack, MD, MPH, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215; e-mail: jennifer_mack{at}

Purpose National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death.

Patients and Methods We studied 1,231 patients with stage IV lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a population- and health system–based prospective cohort study, who died during the 15-month study period but survived at least 1 month. Our main outcome measure was the aggressiveness of EOL care received.

Results Nearly half of patients received at least one marker of aggressive EOL care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%). Patients who had EOL discussions with their physicians before the last 30 days of life were less likely to receive aggressive measures at EOL, including chemotherapy (P = .003), acute care (P < .001), or any aggressive care (P < .001). Such patients were also more likely to receive hospice care (P < .001) and to have hospice initiated earlier (P < .001).

Conclusion Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL.

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