title: Family Perspectives on Aggressive Cancer Care Near the End of Life.
abstract: OBJECTIVE
  Patients with advanced-stage cancer are receiving increasingly aggressive medical care near death, despite growing concerns that this reflects poor-quality care.
  
  
  OBJECTIVE
  To assess the association of aggressive end-of-life care with bereaved family members' perceptions of the quality of end-of-life care and patients' goal attainment.
  
  
  METHODS
  Interviews with 1146 family members of Medicare patients with advanced-stage lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) who died by the end of 2011 (median, 144.5 days after death; interquartile range, 85.0-551.0 days).
  
  
  METHODS
  Claims-based quality measures of aggressive end-of-life care (ie, intensive care unit [ICU] admission or repeated hospitalizations or emergency department visits during the last month of life; chemotherapy ≤2 weeks of death; no hospice or ≤3 days of hospice services; and deaths occurring in the hospital).
  
  
  METHODS
  Family member-reported quality rating of "excellent" for end-of-life care. Secondary outcomes included patients' goal attainment (ie, end-of-life care congruent with patients' wishes and location of death occurred in preferred place).
  
  
  RESULTS
  Of 1146 patients with cancer (median age, 76.0 years [interquartile range, 65.0-87.0 years]; 55.8% male), bereaved family members reported excellent end-of-life care for 51.3%. Family members reported excellent end-of-life care more often for patients who received hospice care for longer than 3 days (58.8% [352/599]) than those who did not receive hospice care or received 3 or fewer days (43.1% [236/547]) (adjusted difference, 16.5 percentage points [95% CI, 10.7 to 22.4 percentage points]). In contrast, family members of patients admitted to an ICU within 30 days of death reported excellent end-of-life care less often (45.0% [68/151]) than those who were not admitted to an ICU within 30 days of death (52.3% [520/995]) (adjusted difference, -9.4 percentage points [95% CI, -18.2 to -0.6 percentage points]). Similarly, family members of patients who died in the hospital reported excellent end-of-life care less often (42.2% [194/460]) than those who did not die in the hospital (57.4% [394/686]) (adjusted difference, -17.0 percentage points [95% CI, -22.9 to -11.1 percentage points]). Family members of patients who did not receive hospice care or received 3 or fewer days were less likely to report that patients died in their preferred location (40.0% [152/380]) than those who received hospice care for longer than 3 days (72.8% [287/394]) (adjusted difference, -34.4 percentage points [95% CI, -41.7 to -27.0 percentage points]).
  
  
  CONCLUSIONS
  Among family members of older patients with fee-for service Medicare who died of lung or colorectal cancer, earlier hospice enrollment, avoidance of ICU admissions within 30 days of death, and death occurring outside the hospital were associated with perceptions of better end-of-life care. These findings are supportive of advance care planning consistent with the preferences of patients.
authors.affiliation: Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
authors.forename: Alexi A
authors.initials: AA
authors.lastname: Wright
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts3Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.affiliation: Institute for Healthcare Policy and Innovation, Division of General Medicine, University of Michigan, Ann Arbor5Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor6Gerald R. Ford School of Public Policy.
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
authors.affiliation: Department of Epidemiology, College of Public Health, University of Iowa, Iowa City.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Chrischilles
authors.affiliation: Rand Corporation, Santa Monica, California9Division of General Internal Medicine, University of California, Los Angeles.
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Kahn
authors.affiliation: Division of Geriatrics, Department of Medicine, University of California, San Francisco.
authors.forename: Christine S
authors.initials: CS
authors.lastname: Ritchie
authors.affiliation: Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jane C
authors.initials: JC
authors.lastname: Weeks
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
authors.forename: Mary B
authors.initials: MB
authors.lastname: Landrum
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001601:Bereavement; D015179:Colorectal Neoplasms / Q000628:therapy*; D003422:Critical Care / Q000592:standards; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005190:Family; D018588:Fee-for-Service Plans; D005260:Female; D017051:Hospice Care / Q000592:standards* / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units; D008175:Lung Neoplasms / Q000628:therapy*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D057240:Patient Preference; D011446:Prospective Studies; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D013727:Terminal Care / Q000592:standards*; D019452:Terminally Ill; D013997:Time Factors; D014481:United States