July 10, 2012

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By Amanda Gardner

MONDAY, July 9, 2012 ( — For patients with terminal cancer who have exhausted all treatment options, being as comfortable and relaxed as possible during their final days often becomes a priority. Staying out of the hospital may be key to attaining that frame of mind, a new study suggests.

Dying at home, avoiding the intensive care unit, and forgoing chemotherapy and feeding tubes in the last week of life are all associated with a better quality of life among end-stage cancer patients, according to the study, which was based on a detailed survey of 396 patients and their caregivers.

"If you want to know how to leave this earth in the best possible way, it wouldn't be seeking futile medicine and medical procedures," says Holly G. Prigerson, Ph.D., the senior author of the study. "It's things like talking with someone, feeling heard, feeling at peace, addressing spiritual struggles or concerns."

Indeed, personal or spiritual connections were nearly as important to patients as being at home. Praying or meditating, receiving visits from a pastor while in a hospital or clinic, and having a good relationship with their oncologists all improved the patients' quality of life, the study found.

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"One of the most important things for patients was having their doctor be emotionally present [and] treating them as a dignified person," says Prigerson, director of the Center for Psychosocial Epidemiology and Outcomes Research at the Dana-Farber Cancer Institute, in Boston. "In a sense, that's encouraging, because it's a modifiable thing."

Many unknowns affect a patient's end-of-life experience, however. The nine factors highlighted in the study accounted for only 20% of the variance in the patients' quality of life. The remaining 80% could be influenced by factors as diverse as a patient's personality traits (such as optimism) and the full arc of care from diagnosis to death, according to an editorial accompanying the study.

Overall, though, the findings suggest that measures to prolong life may actually diminish quality of life. Focusing on reducing a patient's anxiety, and, if possible, moving the patient back home or to a hospice may be more productive.

Next page: Being at home isn't preferable for everyone

But avoiding the hospital isn't always feasible and may not be best for all patients, says Eduardo Bruera, M.D., chair of palliative care and rehabilitation medicine at the University of Texas MD Anderson Cancer Center, in Houston. Bruera was not involved in the study.

Dying at home may be beneficial "when the patient has access to family support, or when the home environment is appropriate, or when the clinical problems are not so severe," Bruera says. On the other hand, he adds, a hospital may be preferable if a patient lacks a good support network or is experiencing physical symptoms, such as pain or shortness of breath.

"Sometimes dying at home is more frightening for the family member, particularly if medical crises emerge that they don't know how to deal with," Prigerson says.

The study findings were published this week in the Archives of Internal Medicine.

Prigerson and her colleagues interviewed patients and their caregivers an average of four months before the patient died. Two to three weeks after the death, the caregivers—as well as the patients' doctors—answered additional questions about the patient's care, physical comfort, and psychological state in the final week of life.

Although the study makes a contribution to the growing body of literature on end-of-life care, the fact that the researchers relied on caregivers and doctors to describe the patient's experience is a shortcoming, says Michael Levy, M.D., director of the pain and palliative care program at Fox Chase Cancer Center, in Philadelphia.

"You just don't know how much…is the caregiver's perception and how much of it is the real patient's quality of life," Levy says. "A daughter may think her mother's quality of life is bad because she can't move, but if the mother can teach the daughter her favorite recipe, the mother might think it's a good day."

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