title: Processes of discontinuing chemotherapy for metastatic non-small-cell lung cancer at the end of life.
abstract: OBJECTIVE
  Administration of chemotherapy close to death is widely recognized as poor-quality care. Prior research has focused on predictors and outcomes of chemotherapy administration at the end of life. This study describes processes of chemotherapy discontinuation and examines their relationships with timing before death, hospice referral, and hospital death.
  
  
  METHODS
  We reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic non-small-cell lung cancer who participated in a trial of early palliative care. Chemotherapy treatments during final regimen were qualitatively analyzed to identify categories of discontinuation processes. We then quantitatively compared predictors and outcomes of the process categories.
  
  
  RESULTS
  A total of 144 patients died, with 81 and 48 receiving intravenous (IV) and oral chemotherapies as their final regimen, respectively. Five processes were identified for IV chemotherapy: definitive decisions (19.7%), deferred decisions or breaks (22.2%), disruptions for radiation therapy (22.2%), disruptions resulting from hospitalization (27.2%), and no decisions (8.6%). The five processes occurred at significantly different times before death and, except for definitive decisions, ultimate decisions for no further chemotherapy and referral to hospice were often made months later. Among patients receiving oral chemotherapy, 83.3% (40 of 48) were switched from IV to oral delivery as their final regimen, sometimes concurrent with or even after hospice referral.
  
  
  CONCLUSIONS
  Date of last chemotherapy is not a proxy for when a decision to stop treatment is made. Patients with metastatic non-small-cell lung cancer stop their final chemotherapy regimen via different processes, which significantly vary in time before death and subsequent end-of-life care.
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan wpirl@partners.org.
authors.forename: William F
authors.initials: WF
authors.lastname: Pirl
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Greer
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Kelly
authors.initials: K
authors.lastname: Irwin
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Inga T
authors.initials: IT
authors.lastname: Lennes
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Vicki A
authors.initials: VA
authors.lastname: Jackson
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Elyse R
authors.initials: ER
authors.lastname: Park
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Fujisawa
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Alexi A
authors.initials: AA
authors.lastname: Wright
authors.affiliation: Massachusetts General Hospital Cancer Center; Dana-Farber Cancer Institute, Boston; Harvard University, Cambridge, MA; and Keio University School of Medicine, Tokyo, Japan.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Temel
mesh_terms: D061605:Administration, Intravenous; D000284:Administration, Oral; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy* / Q000401:mortality / Q000556:secondary; D016208:Databases, Factual; D057286:Electronic Health Records; D005260:Female; D017051:Hospice Care; D017052:Hospital Mortality; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D013727:Terminal Care / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D028761:Withholding Treatment
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