2. Disease-specific Mortality Rates in USA
Total Number of Deaths
800,000
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
US Census Bureau 2010
Total Number of Deaths
3. Death and Dying
• 20% sudden death
• MI
• Trauma
• PE
• 80% death from chronic illnesses
• Cardiovascular diseases
• Cancer
• COPD
5. Where do People Die?
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National Mortality Followback Survey (NMFS)
10,122 deaths analyzed in 1993
58% patients died in Hospital
22% died at home
20% in Nursing Home
Teno JM et al. Med Care 2003;41:323-35
6. Deaths in ICU
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552,157 deaths in 1999 in FL, MA, NJ, NY, VA, WA
38.3% of deaths in hospitals
22.4% of deaths after ICU admission
Death in ICU after a median LOS of 12.9 days
Cost: $24,541.00
Angus DC et al. Crit Care Med 2004;32:638-43
7. ICU use in Last Month of Life
• Were these patients offered the opportunity to
discuss their preferences?
Teno JM et al. JAMA 2013;309:3470-477
8. Discomfort and Lack of Training
• Medical oncologists do not routinely discuss prognosis
• Survey of 729 MD Oncologists
• 73% admitted that training on prognosis communication was lacking
• 96% believed that such education should be part of cancer care
training
• Physicians caring for advanced cancers
• Provide frank estimate 37%
• No estimate or inaccurate estimate (consciously) 63%
• Physicians tend to make different treatment
recommendations to their patients than they would
choose for themselves
Daugherty CK et al. J Clin Oncol 2008;26:5988-93 Lamont EB et al. Ann Intern Med 2001;134:1096-105 Ubel PA et al. Arch Intern Med 2011;17:630-4
9. Physicians Reluctance on EOL care
• > 4000 physicians surveyed
• Most physicians would not discuss EOL options with
terminally ill patients who are feeling well
• They rather wait for symptoms to develop
• They may discuss prognosis when they have no more
treatment to offer
• They do not discuss sites of death (that would
respect patient’s preferences)
Keating NL et al. Cancer 2010;116:998-1006
10. Timing of EOL discussions
• A majority (55%) of patients with cancer at MD
Anderson did not access PC before they died
• PC at 1.4 month before death
• 55% EOL-care discussions occurred in the hospital
• Oncologists documented EOL-care discussions with
only 27% of patients
• Among 959 patients with documented EOL-care
discussions who died during follow-up, discussions
took place a median of 33 days before death
Hui D et al. 2012;17:1574-80
Mack J et al. Ann Intern Med 2012;156:204-10
11. Other Barriers to EOL Discussions
• Most physicians lack knowledge or insight into a
meaningful discussion about prognosis
• Misinterpretation of what patients/surrogates want
• Fear of judgment
• Perfect is sometimes the enemy of the good
• Most surrogates want physicians to disclose
prognostic estimates even if they cannot be certain
of their accuracy
Evans LR et al. Am J Resp Crit Care Med 2009:179:48-53
14. Data from MSKCC
• Identification of poor prognostic factors among patients
requiring mechanical ventilation after HSCT
Bach et al. Blood 2001
15. Accuracy of Prognosis
• Estimate of survival time in individual patients
with cancer can be accurate
Glare P A et al. JCO 2013;31:3565-3571
16. Cardiac Arrest
• OHCA carries 92% mortality
• CPR in hospitalized patients
• ROSC: 44%
• Alive at hospital discharge: 17%
• CPR in ICU patients
• Hospital survival: 15.9%
• VP, MV, and age > 65 y (worse outcome)
• CPR in patients with cancer
• Survival: 10.1% for general medical/surgical wards
• 2.2% in ICU
Roger VL et al. Ciculation 2011;123:e18-209
Tian J et al. Am J Respir Crit Care Med 2010;182:501-6
Peberdy MA et al. Resuscitation 2003;58:297-308
Reisfield GM et al. Resuscitation 2006;71:152-60
17. Place of Death: QOL and Caregiver MH
• Prospective, longitudinal study of terminally ill
patients with cancer and their caregivers at
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Yale Cancer Center
West Haven VA CT Comprehensive Cancer Clinic
Simmons Comprehensive Cancer Center
Parkland Hospital
MSKCC
Dana-Farber
New Hampshire Oncology-Hematology
• Study population: 342 dyads
• Hospital deaths associated with prolonged grief
• ICU deaths associated with higher risk of PTSD
Wright AA et al. J Clin Oncol 2010;28:4457-4464
18. EOL Discussions and Outcomes
• 325 patients from 8 sites
• 68% received EOL care consistent with thir
preferences
• Patients more likely to receive EOL care consistent
with preferences if wishes were discussed with
physicians
• Distress lower among patients who received no lifeextending measures and their caregivers
Mack JW et al. J Clin Oncol 2010;28:1203-1208
19. Domains of EOL Discussions in ICU
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Communication
Seek patient’s preferences
Support to family/surrogate
Spiritual needs
Relief of symptoms
Support caregiver grieving (SW + Psychiatry)
Use of available resources
EOL care after death
20. Benefits of PC-ICU
Outcome
Selected Relevant Studies
↓ Intensive care unit/hospital length of stay
Campbell et al; Norton et al; Curtis et al
↓ Use of nonbeneficial treatments
Campbell et al; O’Mahony et al; Pierucci et al
↓ Duration of mechanical ventilation
Payen et al
↑ Family satisfaction/comprehension
Azoulay et al
↓ Family anxiety/depression, PTSD
Lautrette et al
↓ Conflict over goals of care
Lilly et al
↓ Time from poor prognosis to comfort-focused goals Campbell et al
↑ Symptom assessment/patient comfort
Nelson et al. Crit Care Med 2010;38:1765-1772
Erdek and Pronovost ; Chanques et al
23. Recommendations
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Would I be surprised if the patient dies in < 1 y?
EOL Discussion in clinic or on admission
Inquire about patient’s preferences
Include surrogate or agent with patient’s
permission
• Shared decision making process
• Discuss options