Aggressive end-of-life care among older adults with metastatic cancer remains common, and is even more common among nursing home residents than in community-dwelling residents.1 “This is despite intensive efforts in the past decades to curb aggressive end-of-life care — and despite the wide recognition that such care is associated with little or no benefit,” says lead author Siran Koroukian, PhD, professor in the department of population and quantitative health sciences at Case Western Reserve University School of Medicine in Cleveland.
Koroukian and colleagues analyzed end-of-life care for 146,329 adults with cancer between 2013 and 2017. They found 64% of nursing home residents received aggressive end-of-life care vs. 58% of community-dwelling residents. Indicators of aggressive end-of-life care included at least one hospital admission in the last 30 days of life, enrollment in hospice in the last three days of life, ICU admission, and in-hospital death. “Our study is dealing with large databases and not individuals,” Koroukian notes.
However, the findings do raise ethical questions about how patient or family preferences are communicated to the care team at the hospital, the timing of those discussions, and what policies are in place at the nursing home to honor patients’ goals of care. “Healthcare providers, and the systems where they work, have a responsibility to ensure that discussions regarding end-of-life care take place, and that, when feasible, patient wishes are honored,” emphasizes Sara L. Douglas, PhD, RN, another study author and the Gertrude Perkins Oliva professor in oncology nursing at Case Western.
Researchers in this space have similar ethical obligations. “Personal and cultural beliefs that potentially influence wishes for end-of-life care must be respected by researchers when conducting studies in the area of aggressive end-of-life care,” Douglas advises.
When end-of-life care is provided in the nursing home, providers typically do not have access to ethics committees or full-time ethicists, notes Jason T. Eberl, PhD, director of the Albert Gnaegi Center for Health Care Ethics at Saint Louis University. If a nursing home is affiliated with a hospital or owned by a healthcare system, then ethics support might be available. “As business entities, nursing homes may be more concerned about potential lawsuits if they do not provide aggressive end-of-life care per family requests or presumed expectations,” Eberl notes.
Certain forms of aggressive treatment, even if families demand it, might constitute “abuse” of the patient. If family members (or other appropriate surrogate decision-makers) opt for interventions the care team believes are abusive to the patient, the nursing home may petition the court to appoint a neutral guardian ad litem to make medical decisions. The central ethical concern, says Eberl, “is whether the resident’s wishes, whether explicitly expressed previously or not, regarding end-of-life treatment are being followed.”
REFERENCE
1. Koroukian SM, Douglas SL, Vu L, et al. Incidence of aggressive end-of-life care among older adults with metastatic cancer living in nursing homes and community settings. JAMA Netw Open 2023;6:e230394.
Recent research findings raise ethical questions about how patient or family preferences are communicated to care providers, the timing of those discussions, and what policies are in place at the nursing home to honor patients’ goals of care.
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