One-third (33% to 38%) of older patients with advanced irreversible disease hospitalized near the end of life in one of ten countries—including the U.S.—received interventions unlikely to provide either survival or palliation benefit, according to a report published in the International Journal for Quality in Health Care.
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“Our focus is on aggressive active management beyond comfort care in the last six months of life, when the clinical presentation should have signaled the time for transition from aggressive to palliative or comfort care,” write the authors.
Investigators reviewed 38 studies published in English from 1995 to 2015 covering 1.2
million terminally ill patients, their bereaved relatives, physicians and nurses in the U.S., Europe, the U.K., Canada, Brazil, Taiwan, South Korea, and Australia.
Because of a lack of agreed definitions across studies for “too much,” “futile,” “inappropriate” or “disproportionate” care for patients nearing the end of life, the researchers chose the term “non-beneficial treatment” (NBT) as most acceptable for indicating “a treatment that was administered with little or no hope of its having any effect, largely because of the underlying state of the patient’s health and the known or expected poor prognosis regardless of treatment.”
The most commonly reported measurable NBTs were:
- Intensive care unit (ICU) admissions for patients with advanced incurable disease
and/or previously stated limitations on end-of-life treatment
- Cardiopulmonary resuscitation (CPR) administered to terminal patients, both those with and without do-not-resuscitate (DNR) orders
- Initiation or continuation of chemotherapy in the last 30 to 14 days of life
- “We also found evidence of unnecessary imaging, such as x-rays (25% to 37%) and blood tests (49%),” the authors report. “Many patients were treated for a number of other underlying conditions with oral or intravenous medicines that made little or no difference to their survival and were inconvenient and in some cases, harmful.”
Key NBTs in Patients with Terminal Illness
- Overall CPR attempts, mean 28% (range, 11% to 90%)
- CPR attempts on patients with a DNR order, 11% to 25%
- Non-beneficial ICU admission, mean 10% and up to 33%
- Chemotherapy in the last six weeks of life, mean 33% (24% to 41%)
- Active measures with no benefit including dialysis, radiotherapy, transfusions and life support treatment, 30% (7% to 77%)
- Non-beneficial administration of antibiotics or cardiovascular, digestive and endocrine treatments, 38% (11% to 75%)
- Unnecessary use of emergency consultations in the last three months of life, 50%
While the prevalence of NBTs varies by patient condition, health system and type of aggressive treatment, “overall the findings strongly indicate the persistence of ambiguity about what is deemed non-beneficial, and a culture of ‘doing everything possible’ even if it is against expressed patients’ wishes,” the authors point out.
The widespread use of NBTs has repercussions that affect the sustainability of health services, perpetuate unrealistic expectation of survival at all costs and “reflect a disregard for human dignity and quality care at the end of life,” note the authors. They suggest that a combination of factors may influence the continuing use of NBTs.
Reasons for Use of NBTs
Intervention as the default option.
“The long-held perception of death as treatment failure still leads to prolongation of treatment,” note the authors. “Admission to an acute hospital and prevention of death
through clinical intervention are often the default positions, whether a patient has a reversible component to their disease or whether they are at their natural end of life.”
Unrealistic societal expectation of survival due to technological advances.
“Advances in medical technology have fueled unrealistic expectations of the healing power of doctors and the tools at their disposal. This is particularly the case in the treatment of the elderly,” write the authors.
Family pressure for physicians to “try everything possible.”
The authors explain, “According to clinicians, family requests to continue treating their elderly relative at the end of their life—due to poor acceptance of prognosis, cultural beliefs and disagreements with medical decisions—are the main reason for provision of non-beneficial treatment.”
“Patients and families, if they ask, are entitled to the truth about the approximate time they have remaining, even when it contains an element of uncertainty, which of course also needs to be explained,” comment the authors. “The exact percentage chance of survival or number of months or days to death may not be as important as the full understanding of the concept of an impending death.”
Lack of communication between patients/families and their physicians about end-of-life care wishes.
“Holding a timely and honest conversation with an opportunity for questions empowers
patients and families to put a stop to non-beneficial treatments when medicine cannot offer anything further,” state the authors. “This does not mean clinicians or families are abandoning their patient.”
Source: “Non-Beneficial Treatments in Hospital at the End of Life: A Systematic Review on Extent of the Problem,” International Journal for Quality in Health Care; Epub ahead of print, June 27, 2016; DOI: 10.1093/intqhc/mzw060. Cardona-Morrell M, et al; The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, Sydney, Australia.