提前临终谈话可避免晚期癌症不必要治疗

《临床肿瘤学杂志》11月13日在线发表的一项纳入1,231例患者的研究显示，在临终30天前与照顾者讨论临终事宜的Ⅳ期肺癌或结直肠癌患者，在临终前接受积极治疗的几率显著较低，且接受临终关怀的几率更高，时间也更早。

近半数(47%)患者在临终30天接受了某种积极治疗，其中16%在临终前14天内仍接受化疗，6%在临终前30天内仍接受ICU治疗，40%在临终前30天内仍在医院接受紧急治疗(doi:10.1200/JCO.2012.43.6055)。

这些数据来自于在美国5个州的健康维护组织(HOM)或退伍军人事务部医疗中心接受治疗的2,155例Ⅳ期肺癌或结直肠癌患者。对所有患者随访15个月。前期研究显示，大多数医生在患者死亡前与其进行临终讨论，但讨论时间与死亡时间较为接近。

本项研究纳入1,231例最终死亡但诊断后至少存活1个月的患者，以评价临终讨论的时机是否会影响临终治疗。82%为肺癌患者，其余为结直肠癌患者。

88%的患者进行了临终讨论。23%的讨论是由患者或其代理人在访谈中报告而未被记入病历，17%在病历中记录但未由患者或代理人报告，48%则二者兼有。

在794例病历中记录有临终讨论的患者中，39%的临终讨论在临终30天进行，63%在住院时进行，40%涉及肿瘤科医生。58%的患者接受临终关怀，其中15%的临终关怀在临终7天进行。

在报告有临终讨论的患者中，临终2周接受化疗的几率降低59%，临终30天接受急性治疗的几率降低57%，临终30天接受ICU治疗的几率降低23%。

住院期间进行首次临终讨论的患者在临终时接受任何形式积极治疗的几率增加1倍多，临终30天接受急性治疗或ICU治疗的几率增加2倍多，临终7天接受临终关怀的几率也增加2倍多。

内科肿瘤医生参与首次临终讨论使临终2周接受化疗的几率增加48%，临终30天接受ICU治疗的几率降低56%，接受临终关怀的几率增加43%，临终7天接受临终关怀的几率增加1倍。在校正其他因素后，所有这些比值比均具有显著性。

排除退伍军人事务部医疗中心的患者或排除与患者代理人进行的访谈后，进行次要分析得出的结果与主要分析得出的结果相似。

既往研究表明，医生们通常不愿意较早开展临终讨论，担心这么做会对患者的心理造成负面影响，令其产生绝望感，但目前尚无明确证据支持这种观点。研究者建议，医生们应在诊断后不久即开展临终护理讨论，此时患者的健康状况相对较好且有时间计划以后的事情。此外，应多次进行此类讨论，因为患者需要一定时间来消化此类信息和进行考虑。未来有必要开展进一步工作，探讨为什么一些在病历中记录的临终讨论未被患者或代理人报告。研究者表示，有时医生已经跟患者进行谈话，但患者未听进或未理解，因此有必要询问患者从对话中获得了什么信息，并根据这些信息指导以后的工作。

相关评论：讨论时机至关重要


J. Randall Curtis博士

华盛顿大学卓越姑息治疗中心主任J. Randall Curtis博士在接受采访时表示，这项重要研究表明，对Ⅳ期癌症患者进行早期临终讨论与临终治疗强度的降低相关，并且开展讨论的时机非常重要，应提早进行。在诊断后不久即进行临终讨论无疑具有实际意义，但早期讨论并不意味后期讨论就不必要或不重要。早期讨论的开展有利于在患者病情恶化时更易于开展后期讨论。目前需要发展有效的培训项目，通过向医生们教授沟通技巧，帮助其在临床上开展此类临终讨论。此外，还需开展进一步研究，探讨如何才能最好地在临床上开展早期讨论，以及研究此类做法的长期效果。

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By: SHERRY BOSCHERT, Oncology Practice

Patients with stage IV lung or colorectal cancer who had end-of-life discussions with caregivers before the last 30 days of life were significantly less likely to receive aggressive care in their final days and more likely to get hospice care and to enter hospice earlier, a study of 1,231 patients found.

Nearly half received some kind of aggressive care in their last 30 days (47%), including chemotherapy in the last 14 days (16%), ICU care in the last 30 days (6%), and/or acute hospital-based care in the last 30 days of life (40%), Dr. Jennifer W. Mack and her associates reported.
 
Multiple current guidelines recommend starting end-of-life care planning for patients with incurable cancer early in the course of the disease while patients are relatively stable, not when they are acutely deteriorating.

Many physicians in the study postponed the discussion until the final month of life, and many patients didn’t remember or didn’t recognize the end-of-life discussions. Discussions that were documented in charts were not associated with less-aggressive care or greater hospice use, if patients or their surrogates said no end-of-life discussions took place.

Eighty-eight percent of patients in the current study had end-of-life discussions. Twenty-three percent of the discussion were reported by patients or their surrogates in interviews but not documented in records, 17% were documented in medical records but not reported by patients or surrogates, and 48% were both reported and documented.

Among the 794 patients with end-of-life discussions documented in medical records, 39% took place in the last 30 days of life, 63% happened in the inpatient setting, and 40% included an oncologist. Fifty-eight percent of patients entered hospice care, which started in the last 7 days of life for 15% of them, reported Dr. Mack, a pediatric oncologist at the Dana-Farber Cancer Institute and Harvard Medical School, Boston.

The study was published online Nov. 13, 2012 by the Journal of Clinical Oncology (doi:10.1200/JCO.2012.43.6055).

Chemotherapy in the last 2 weeks of life was 59% less likely, acute care in the last 30 days was 57% less likely, and ICU care in the last 30 days was 23% less likely when patients or surrogates reported having end-of-life discussions.

Patients Followed 15 Months After Diagnosis

Patients whose first end-of-life discussion happened while they were hospitalized were more than twice as likely to get any kind of aggressive care at the end of life and three times more likely to get acute care or ICU care in the last 30 days and to have hospice care start within the last week before death.

Having a medical oncologist present at the first end-of-life discussion increased the odds of having chemotherapy in the last 2 weeks of life by 48%, decreased the odds of ICU care in the last 30 days by 56%, increased the likelihood of hospice care by 43%, and doubled the chance of hospice care starting in the last 7 days of life. All of these odds ratios were significant after controlling for other factors.

Data came from a larger cohort of 2,155 patients with stage IV lung or colorectal cancer receiving care in HMOs or Veterans Affairs medical centers in five states. All were followed for 15 months after diagnosis in the Cancer Care Outcomes Research and Surveillance Consortium.

An earlier analysis by the same investigators showed that 87% of the 1,470 patients who died and 41% of the 685 still alive by the end of follow-up had end-of-life care discussions, but oncologists documented end-of-life discussions with only 27% of their patients, suggesting that most discussions were with non-oncologists. Among those who died, documented discussions took place a median of 33 days before death (Ann. Intern. Med. 2012;156:204-10).

"Our previous study on this database found that most physicians do have end-of-life discussions before death, but most occur near the end of life," Dr. Mack said in an interview.