title: Opportunity lost: end-of-life discussions in cancer patients who die in the hospital.
abstract: BACKGROUND
  End-of-life discussions are associated with decreased use of life-sustaining treatments in patients dying of cancer in the outpatient setting, but little is known about discussions that take place during terminal hospitalizations.
  
  
  OBJECTIVE
  To determine the proportion of patients assessed by the clinical team to have decisional capacity on admission, how many of these patients participated or had a surrogate participate in a discussion about end-of-life care, and whether patient participation was associated with treatments received.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  Inpatient.
  
  
  METHODS
  Adult patients with advanced cancer who died in the hospital between January 1, 2004 and December 31, 2007.
  
  
  RESULTS
  Of the 145 inpatients meeting inclusion criteria, 115 patients (79%) were documented to have decisional capacity on admission. Among these patients, 46 (40%) were documented to lose decisional capacity prior to an end-of-life discussion and had the discussion held instead by a surrogate. Patients who had surrogate participation in the end-of-life discussions were more likely to receive mechanical ventilation (56.5% vs 23.2%, P < 0.01), artificial nutrition (45.7% vs 25.0%, P = 0.03), chemotherapy (39.1% vs 5.4%, P <0.01), and intensive care unit (ICU) treatment (56.5% vs 23.2%, P <0.01) compared to patients who participated in discussions. There was no difference between palliative treatments received.
  
  
  CONCLUSIONS
  The majority of patients with advanced cancer are considered to have decisional capacity at the time of their terminal hospitalization. Many lose decisional capacity before having an end-of-life discussion and have surrogate decision-makers participate in these discussions. These patients received more aggressive life-sustaining treatments prior to death and represent a missed opportunity to improve end-of-life care.
authors.affiliation: Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, Washington, USA. mzaros@uw.edu
authors.forename: Mark C
authors.initials: MC
authors.lastname: Zaros
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Maria J
authors.initials: MJ
authors.lastname: Silveira
authors.forename: Joann G
authors.initials: JG
authors.lastname: Elmore
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D009369:Neoplasms / Q000401:mortality* / Q000523:psychology / Q000628:therapy*; D010166:Palliative Care / Q000379:methods / Q000523:psychology / Q000592:standards*; D010358:Patient Participation / Q000379:methods / Q000523:psychology; D012042:Registries; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods / Q000523:psychology / Q000592:standards*