title: Associations between palliative chemotherapy and adult cancer patients' end of life care and place of death: prospective cohort study.
abstract: OBJECTIVE
  To determine whether the receipt of chemotherapy among terminally ill cancer patients months before death was associated with patients' subsequent intensive medical care and place of death.
  
  
  METHODS
  Secondary analysis of a prospective, multi-institution, longitudinal study of patients with advanced cancer.
  
  
  METHODS
  Eight outpatient oncology clinics in the United States.
  
  
  METHODS
  386 adult patients with metastatic cancers refractory to at least one chemotherapy regimen, whom physicians identified as terminally ill at study enrollment and who subsequently died.
  
  
  METHODS
  
  
  
  METHODS
  intensive medical care (cardiopulmonary resuscitation, mechanical ventilation, or both) in the last week of life and patients' place of death (for example, intensive care unit).
  
  
  RESULTS
  survival, late hospice referrals (≤ 1 week before death), and dying in preferred place of death.
  
  
  RESULTS
  216 (56%) of 386 terminally ill cancer patients were receiving palliative chemotherapy at study enrollment, a median of 4.0 months before death. After propensity score weighted adjustment, use of chemotherapy at enrollment was associated with higher rates of cardiopulmonary resuscitation, mechanical ventilation, or both in the last week of life (14% v 2%; adjusted risk difference 10.5%, 95% confidence interval 5.0% to 15.5%) and late hospice referrals (54% v 37%; 13.6%, 3.6% to 23.6%) but no difference in survival (hazard ratio 1.11, 95% confidence interval 0.90 to 1.38). Patients receiving palliative chemotherapy were more likely to die in an intensive care unit (11% v 2%; adjusted risk difference 6.1%, 1.1% to 11.1%) and less likely to die at home (47% v 66%; -10.8%, -1.0% to -20.6%), compared with those who were not. Patients receiving palliative chemotherapy were also less likely to die in their preferred place, compared with those who were not (65% v 80%; adjusted risk difference -9.4%, -0.8% to -18.1%).
  
  
  CONCLUSIONS
  The use of chemotherapy in terminally ill cancer patients in the last months of life was associated with an increased risk of undergoing cardiopulmonary resuscitation, mechanical ventilation or both and of dying in an intensive care unit. Future research should determine the mechanisms by which palliative chemotherapy affects end of life outcomes and patients' attainment of their goals.
authors.affiliation: Harvard Medical School, Department of Medical Oncology, Dana-Farber Cancer Institute, Dana 1133, 450 Brookline Avenue, Boston, MA 02215, USA.
authors.forename: Alexi A
authors.initials: AA
authors.lastname: Wright
authors.forename: Baohui
authors.initials: B
authors.lastname: Zhang
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.forename: Jane C
authors.initials: JC
authors.lastname: Weeks
authors.forename: Holly G
authors.initials: HG
authors.lastname: Prigerson
mesh_terms: D000328:Adult; D003422:Critical Care / Q000706:statistics & numerical data; D003643:Death; D005260:Female; D006738:Hospices / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy; D010166:Palliative Care / Q000379:methods* / Q000706:statistics & numerical data; D057240:Patient Preference / Q000706:statistics & numerical data; D011446:Prospective Studies; D016019:Survival Analysis; D013727:Terminal Care / Q000706:statistics & numerical data*; D019452:Terminally Ill / Q000706:statistics & numerical data