An Obvious Call for Better Communication

By Steven J Baumrucker, MD

(this editorial ran in a slightly different form in The American Journal of Hospice and Palliative Care)

It has been satisfying to see increasing interest in palliative and end-of-life care in the mainstream medical journals recently. The Journal of the American Medical Association, The New England Journal of Medicine, and Annals of Internal Medicine have all run articles this year (see footnotes). JAMA particularly seems to have taken an editorial turn, averaging nearly an article per issue in the last several weeks.
The debate over physician-assisted suicide has certainly played a large role in promoting critical thinking in issues at the end of life. However stimulating this issue is, however, there are other important topics covered recently in the literature. Due to the volume of the dialogue over assisted suicide, some of these issues may be being overlooked.
One of the most interesting articles of this sort appeared in JAMA in June. In "Relationship Between Cancer Patient Predictions of Prognosis and Their Treatment Preferences," author Jane C. Weeks, MD and her associates studied 917 adults with advanced non-small cell lung cancer or colon cancer metastatic to liver. They tallied physician estimates of survival, patient estimates of survival, and actual survival time. The proportion of patients choosing "curative" therapy over palliative care was compared and matched to the survival estimates. The results were depressing and not at all surprising.
The team found that physicians were rather good at estimating survival time in patients with advanced cancer. They also found that patients were significantly less accurate, tending to overestimate survival. For example, 59% (n= 543) of the patients gave themselves a total probability of greater than 90% of surviving six months, but only 58% (n= 314) of those patients were actually alive at the six month point. Of the 238 patients that gave themselves a greater than 75% chance of surviving six months, only 74 (31%) lived that long. In contrast, the physicians gave only 58 patients a greater than 90% chance of survival, and at the end of the six month period, 41 (71%) of them were still alive.
Of course, this begs the question "so what?" Physicians would normally be expected to be better at estimating prognosis than patients, and it seems to be human nature to be overly optimistic when it comes to faith in our medical system's ability to cure disease. The problem is, that patients who overestimated their survival tended to choose so-called "life-extending" care (chemotherapy, radiotherapy, etc.,) over "quality-of-life" care, i.e., palliative care. Although patients who estimated their survival in the high range did tend to live longer, those who chose life-extending therapy showed no statistically significant increase in survival over those who didn't. Also,
"Patients who preferred life-extending therapy were 1.6 times more likely to experience a readmission to the hospital, an attempted resuscitation, or death while receiving ventilatory assistance than patients who preferred therapy directed at pain relief..."
So patients who chose curative therapy had more negative quality of life events, and did not live significantly longer than the palliative care cohort.
The authors posit that one of the implications of this study is that enhanced communication on prognosis between physician and patient would probably help patients make better-informed treatment decisions. They also suggest that the study could be used "to justify an intervention study to examine the issue." Are we really still in a place in American medicine that we need scientific studies to tell us that we need to talk honestly and directly to our patients? Do we need science to tell us that properly transmitted information and dialogue from the medical team (not just the physicians) to the patient (and family) is the key to appropriate decision-making?
The problem is not so much communication in general, but rather the ability to communicate when it comes to the subject of death and dying. Health care providers are notoriously bad at this skill, probably because it is rarely taught in training.
Perhaps one intervention that could be studied in the future is the "new paradigm" of palliative care, that which integrates palliation into standard care, with an increasing or decreasing role as time goes on, depending on the need of the patient. Previously, one received "curative" therapy until hope was exhausted, then the hospice and palliative medicine team was called. This led to the graphic interpretation in figure 1.
Intuitively, it seems better to involve the palliative team early, and allow an increasing role as needed, finally making a smooth transition to total symptom care
if the curative therapy fails (figure 2). Now that Dr. Weeks and her team have given us the benchmark data, perhaps we can finally try to prove that this idea's time has come.
There is another interesting finding in this study. It seems that physicians are better at estimating survival than we thought in the past. What then explains the chronic problem of late referrals to hospice? Perhaps correcting the communication problem by introducing the concept of palliative care early in the course of therapy will fix this problem also, and automatically as well. Although this may sound utopian, it may be that most of the problems hospice and palliative care teams face at present can be easily corrected with a simple shift in the present medical care model. The time is right to take our system of palliative physicians, nurses, social worker, chaplains, aides, and others to "the next level," and if it takes new research leading to obvious results to convince us all, so be it. The quality of life of a significant fraction of our patients is at stake.
Bernabei R et al. Management of Pain in Elderly Patients With Cancer. JAMA. 1998; 279(23): 1877.
Gureje O et al. Persistent Pain and Well-being. JAMA. 1998; 280(2): 147.
Emanuel E et al. What Are the Potential Cost Savings from Legalizing Pysician-Assisted Suicide? NEJM. 1998; 339(3): 167.
Miller F et al. Voluntary Death: A Comparison of Terminal Dehydration and Physician-Assisted Suicide. Ann Int Med. 1998; 128: 559. Weeks JC et al. Relationship Between Cancer Patient Predictions of Prognosis and Their Treatment Preferences. JAMA. 1998; 279(21): 1709.