title: Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study.
abstract: OBJECTIVE
  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.
  
  
  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).
  
  
  CONCLUSIONS
  Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL.
authors.affiliation: Dana-Farber Cancer Institute, Boston, MA 02215, USA. jennifer_mack@dfci.harvard.edu
authors.forename: Jennifer W
authors.initials: JW
authors.lastname: Mack
authors.forename: Angel
authors.initials: A
authors.lastname: Cronin
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.forename: Nathan
authors.initials: N
authors.lastname: Taback
authors.forename: Haiden A
authors.initials: HA
authors.lastname: Huskamp
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Malin
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.forename: Jane C
authors.initials: JC
authors.lastname: Weeks
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000523:psychology; D000368:Aged; D000369:Aged, 80 and over; D001293:Attitude to Death; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000523:psychology / Q000628:therapy*; D003657:Decision Making; D005260:Female; D017051:Hospice Care / Q000523:psychology / Q000592:standards*; D006801:Humans; D008175:Lung Neoplasms / Q000523:psychology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D011446:Prospective Studies; D013727:Terminal Care / Q000523:psychology / Q000592:standards*; D055815:Young Adult