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Email reminders encourage end-of-life talks

By Genevra Pittman

NEW YORK (Reuters Health) - Email alerts may encourage cancer doctors to talk with terminally ill patients about their end-of-life wishes and to record those preferences in their medical records, a new study suggests.

Oncologists who were reminded each time one of their patients started a new chemotherapy regimen were more than twice as likely to note patients' wishes before they became very sick, researchers found.

"If, God forbid, the patient does end up in a medical emergency and it's unclear what their medical wishes are, then it's always a difficult situation for the doctor and the family," said Dr. Jennifer Temel, who led the study at Massachusetts General Hospital Cancer Center in Boston.

Doctors tend to wait for a patient's condition to get much worse before bringing up their end-of-life wishes, such as whether they want health care staff to use CPR and other measures to try to prolong their lives, she said. But reminders may help them initiate those discussions earlier.

"Patients in the inpatient settings are in crisis, and it's a highly emotional state for patients and their families," Temel told Reuters Health.

"Everybody thinks it's better to have these conversations when people are less ill" - before they end up in the hospital, for example.

She and her colleagues surveyed doctors and nurse practitioners about their end-of-life conversations with people with incurable cancer, including how the health care providers would like to be prompted to have those conversations.

Then, the researchers designed and tested an email system that reminded doctors when they were seeing patients who were coming in to start a new chemo regimen.

The study included 100 people with advanced lung cancer. A year after the email alerts began, just over one-third of the patients had end-of-life wishes documented in their electronic health records.

In comparison, during the pre-alert period less than 15 percent of people diagnosed with incurable lung cancer had had their wishes written down before they were hospitalized, according to findings published in the Journal of Clinical Oncology.

During both time periods, most patients who had end-of-life wishes recorded were listed as do not resuscitate (DNR) or do not intubate (DNI), meaning they didn't want doctors to take aggressive measures to keep them alive at the end.

Not only are such measures sometimes against a patient's wishes, they can also be very expensive.

According to data from the Dartmouth Atlas of Health Care, 32 percent of total Medicare spending goes toward caring for very sick patients in their last two years of life. In the early 2000's, that spending totaled about $46,000 per chronically-ill patient.

"In the absence of these discussions, patients may receive unwanted, overly aggressive care that incurs cost for the patient and society and is associated with decreased quality of life for the patients and family and worsened bereavement adjustment for caregivers," wrote Dr. Jamie Von Roenn, in an editorial published with the new study.

The change seen with email alerts "is an improvement, but we still have a long way to go," added Von Roenn, a palliative medicine specialist from Northwestern University's Feinberg School of Medicine in Chicago.

Temel said patients and their families should know that end-of-life discussions are part of comprehensive cancer care.

"They should feel comfortable initiating these conversations too," she said.

SOURCE: http://bit.ly/S6L6HF Journal of Clinical Oncology, online January 2, 2013.