Videos may aid end-of-life care decisions
NEW YORK (Reuters Health) - Videos that depict different options for end-of-life care may help terminally ill cancer patients decide on what they want, a new study suggests.
Research shows that only a minority of cancer patients complete documents on advance care planning -- and that even when doctors and patients have discussions on end-of-life care, poor communication and patients' lack of medical knowledge remain significant obstacles.
"There are well known communication barriers in the patient-doctor relationship," Dr. Angelo E. Volandes, the senior researcher on the new study, told Reuters Health in an email.
Using video to supplement end-of-life discussions "helps surmount some of these barriers," said Volandes, of Harvard Medical School and Massachusetts General Hospital in Boston.
For their study, Volandes and his colleagues randomly assigned 50 patients with malignant glioma -- a form of brain cancer with a typically poor prognosis -- to one of two groups. Patients in one group were given only a verbal description of their options for care once their cancer had become "very advanced," while those in the other group also watched a video.
The video depicted images of three general choices for end-of-life care. One was life-prolonging care, which aims to extend patients' lives "at all costs," including giving cardiopulmonary resuscitation (CPR) for cardiac arrest and using a mechanical ventilator when patients can no longer breathe on their own.
A second option was basic medical care -- which includes, for example, antibiotics to treat infections and hospitalization if needed, but no extraordinary measures to save the patient's life.
The third option was "comfort care," where patients are given pain medication, supplemental oxygen and other measures to make them comfortable in their last days -- usually outside of a hospital, and often at home.
Volandes and his colleagues found that patients who received verbal information alone were fairly divided on what they wanted. Just over half preferred basic medical care, while one-quarter wanted life-prolonging measures, and only 22 percent preferred comfort care.
In contrast, 91 percent of patients in the video group said they would want comfort care. None preferred life-prolonging care, the researchers report in the Journal of Clinical Oncology.
In addition, the researchers found, patients in the video group showed greater gains in their knowledge of their care options and had higher scores on a measure that gauged patients' certainty in their choices.
Both of those measures, Volandes said, "support the conclusion that patients had more knowledge when they were making their decisions. And when people had more knowledge of the goals of care, they preferred less aggressive care."
Videos may help patients' decision-making simply because pictures often speak louder than words, according to Volandes.
"Videos give more accurate pictures of what these interventions entail and of their success rates," he noted. "Words often do not capture the clinical reality. Pictures often do speak a thousand words."
The study findings come at a time when the costs of end-of-life care are being debated. A study earlier this year in the Archives of Internal Medicine found that terminally ill cancer patients who had end-of-life discussions with their doctors typically chose fewer aggressive measures and had lower healthcare costs near the end of life than those who did not have such discussions.
The researchers said that as U.S. policy makers look for ways to rein in healthcare costs, end-of-life care deserves a closer look. They estimated that if half of the U.S. adults who died of cancer in 2008 had an end-of-life discussion with their doctors, the projected savings would be at least $77 million.
Whether videos ultimately facilitate more of those doctor-patient conversations remains to be seen. Larger clinical trials of patients with different forms of cancer and more-diverse backgrounds are needed, Volandes said.
He and his colleagues will launch such a study next year.
SOURCE: Journal of Clinical Oncology, online November 30, 2009.
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