Quality of Life at the End of Life

For patients dying of cancer who no longer have the option of curative care, the focus of care may shift from prolonging life to improving the quality of life (QOL). The Institute of Medicine issued a report in 1997 on improving care at the end of life (EOL). The report noted that data on the EOL were scarce, particularly on the strongest predictors of higher QOL at the EOL.

To date, few data exist on predictions of better QOL at the EOL for patients with advanced cancer. Researchers recently conducted a study designed to identify the factors that most influence the QOL at the EOL and to establish targets for interventions aimed at promoting QOL at the EOL. They reported study results online in Archives of Internal Medicine [doi:10.1001/archinternmed.2012.2364].

Coping with Cancer, a federally funded study, enrolled 396 patients with advanced cancer and their informal caregivers from September 1, 2002, through February 28, 2008. Patients were followed from enrollment to death (median of 4.1 months after enrollment). The primary outcome of this report was patient QOL in the last week of life.

The majority of the patients were white (65.0%), Christian (71.3%), and insured (60.8%). Just over half (52.4%) had completed high school. Mean age was 58.7 years; median survival after baseline was 125 days.

The patients who were closer to death and younger patients had worse QOL at the EOL. There was an association between caregivers’ overall health and patients’ better QOL at the EOL. Informal caregivers (family) rated the QOL of patients marginally significantly worse than formal caregivers (professional/clinical staff).

In the analysis of potential predictors of QOL at the EOL, patients with major depressive disorder, post-traumatic stress disorder, or panic disorder, and those who were worried at baseline had significantly worse QOL at the EOL. Those with a sense of inner peace at baseline had better QOL at the EOL. Patients whose caregivers had panic disorder had worse QOL at the EOL.

Pastoral care services received within a clinic or hospital were associated with better QOL. In addition, patients whose religious beliefs or activities helped them cope with their illness and those who participated in private religious practices before their diagnosis and at baseline had significantly better QOL at the EOL.

There was also an association between better QOL at the EOL and a strong therapeutic alliance between the patient and physician. Conversely, patients who received any life-prolonging procedure in the last week of life and admittance to an intensive care unit had worse QOL at the EOL. Deaths in the ICU and hospital were associated with significantly worse QOL, whereas deaths at home were associated with significantly better QOL at the EOL.

In conclusion, the researchers commented that, “Taken together, these results indicate that when medicine is no longer able to cure, physicians may still positively and significantly influence the lives of the patients. By reducing patient worry, encouraging contemplation, integrating pastoral care within medical care, fostering a therapeutic alliance between patient and physician that enables patients to feel dignified, and preventing unnecessary hospitalizations and receipt of life-prolonging care, physicians can enable their patients to live their last days with the highest possible level of comfort and care.”