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Last Days of Life (PDQ®)

Overview

Despite progress in developing treatments that have improved life expectancies for patients with advanced-stage cancer, the American Cancer Society estimates that 589,430 people will die from cancer in 2015.[1] People with cancer die under various circumstances. A report of the Dartmouth Atlas Project analyzed Medicare data from 2003 to 2007 for cancer patients older than 65 years who died within 1 year of diagnosis.[2] Across the United States, 29% of patients died in a hospital, with 61.3% hospitalized at least once in the last month of life. In addition, 24% of patients were admitted to an intensive care unit at least once. Approximately 6% of patients nationwide received chemotherapy in the last month of life. Conversely, about 55% of patients who died used hospice service; however, the average length of stay was only 8.7 days, and 8.3% of patients were enrolled in the last 3 days of life. Significant regional variations in the descriptors of end-of-life (EOL) care remain unexplained.

Patient and family preferences may contribute to the observed patterns of care at the EOL. Patient recall of EOL discussions, spiritual care, or early palliative care, however, are associated with less-aggressive EOL treatment and/or increased utilization of hospice.[3-7] In addition, death in a hospital has been associated with poorer quality of life and increased risk of psychiatric illness among bereaved caregivers.[8] (Refer to the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancer for more information.) Thus, it is important to help patients and their families articulate their goals of care and preferences near the EOL.

This summary provides clinicians with information about anticipating the EOL; the common symptoms patients experience as life ends, including in the final hours to days; and treatment or care considerations. The decisions commonly made by patients, families, and clinicians are also highlighted, with suggested approaches. The goal of this summary is to provide essential information for high-quality EOL care.

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

References

  1. American Cancer Society: Cancer Facts and Figures 2015. Atlanta, Ga: American Cancer Society, 2015. Available online. Last accessed January 7, 2015.
  2. Goodman DC, Fisher ES, Chang CH, et al.: Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses. Lebanon, NH: Dartmouth Institute for Health Policy & Clinical Practice, 2010. Available online. Last accessed February 18, 2015.
  3. Wright AA, Zhang B, Ray A, et al.: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300 (14): 1665-73, 2008. [PUBMED Abstract]
  4. Mack JW, Cronin A, Keating NL, et al.: Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol 30 (35): 4387-95, 2012. [PUBMED Abstract]
  5. Balboni TA, Paulk ME, Balboni MJ, et al.: Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. J Clin Oncol 28 (3): 445-52, 2010. [PUBMED Abstract]
  6. Temel JS, Greer JA, Muzikansky A, et al.: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363 (8): 733-42, 2010. [PUBMED Abstract]
  7. Hui D, Kim SH, Roquemore J, et al.: Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer 120 (11): 1743-9, 2014. [PUBMED Abstract]
  8. Wright AA, Keating NL, Balboni TA, et al.: Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. J Clin Oncol 28 (29): 4457-64, 2010. [PUBMED Abstract]
  • Updated: February 18, 2015