SAN FRANCISCO — A minority of patients with relapsed leukemia or lymphoma discussed advance directives with their physicians, according to a survey of 75 such patients at Virginia Commonwealth University in Richmond.
Although 35 (47%) of the patients had an advance directive, just 5 (7%) had ever discussed advance directives with their oncologist, said Dr. Thomas J. Smith at the annual Oncology Congress presented by Reed Medical Education.
“You would think that most of them would have had a discussion about advance directives, about code status with their doctor,” said Dr. Smith, the Massey Endowed Professor of Palliative Care Research and Medicine at VCU. But “in only 2 out of 75 cases had the doctor ever brought it up.”
In initial questioning, only 23% of the patients expressed a desire to discuss advance directives with their oncologist, according to the study. Yet 86% were willing to discuss advanced directives with their admitting hospitalist—a physician they had never met before—and 95% thought it would be important to have this discussion.
In attempting to learn why many patients would not want to discuss this topic with their oncologist, Dr. Smith and his colleagues questioned them closely. During this additional questioning, 48% of the patients said they would, in fact, prefer to discuss advanced directives with their oncologist, and 36% said they would prefer to discuss this topic with their primary care physician. “They want to discuss it with … the doctors who know them best,” Dr. Smith said. They're waiting for us to talk about it first.”
But physicians are often reluctant to initiate this discussion for fear of upsetting the patient or causing the patient to give up hope. In fact, advance directives have never been associated with worse survival in any study, Dr. Smith said. One study even showed that advance directives were associated with a 2.2-fold better chance of survival in patients undergoing bone marrow transplants (J. Clin. Oncol. 2007;25:5643-8).
Other studies have shown that patients who are overly optimistic about survival receive worse end-of-life care. They are more likely to be resuscitated and to die in an ICU or on a ventilator, and less likely to die at home, where most patients would prefer to die. Excessive optimism was not associated with improved survival in this study (JAMA 2008;299:2667-78).
Dr. Smith serves on the speakers bureau for Medtronic Inc., and has received honoraria from UnitedHealthcare, and grant support from the National Cancer Institute and the National Library of Medicine. Reed Medical Education and this news organization are owned by Elsevier.