End-of-life crossroads

When faced with a diagnosis of terminal cancer, patients and their families find themselves at a crossroads. How should they proceed—treat the disease aggressively, or make the last days, weeks or months as comfortable as possible?

In California, many people choose the aggressive path. A recent study by the Dartmouth Atlas Project, prepared for the California Healthcare Foundation, found that compared with the nation as a whole, Californians with advanced-stage cancer are more likely to spend time in a hospital intensive-care unit, receive life support during their last month of life and receive chemotherapy during their last two weeks of life.

The report—titled “Measuring Up? End-of-Life Cancer Care in California”—also concluded that hospice referrals for terminally ill cancer patients are increasing, but still lag behind the U.S. average, and “in some California hospitals, referral to hospice care occurred so close to the day of death that it was unlikely to have provided much assistance or comfort to patients.”

Both in terms of aggressive treatment and hospice care, the study found wide variations by region. Researchers examined data from 2010 and compared it to 2003-07, and Enloe Medical Center was the only Butte County hospital included, though Feather River Hospital also has a cancer center.

So, what is the state of end-of-life cancer care locally?

Rather than push patients toward one path or the other, both Enloe and Feather River are focused on bolstering both options and helping patients make the choice that fits their wishes. Each hospital has a hospice program in addition to cancer centers. Moreover, the hospitals have ramped up efforts to get end-of-life decisions made before a person is given a terminal diagnosis.

“I’m all for choice,” said Toby Brandtman, a case manager at Feather River who helps facilitate patients’ advance planning. “It is not my goal to make sure people get or don’t get aggressive treatment at the end of life. My goal would be that their wishes are honored.”

Articulating those wishes can be difficult for a person with late-stage cancer. He or she might be unable to speak or think clearly, in which case the decisions may fall on emotionally wrought relatives. Even patients who can state their preferences often find themselves torn over the prognosis.

Dr. Michael Baird, executive director of the Enloe Regional Cancer Center, used the analogy of a passenger falling off a cruise ship and flailing in the water. Someone standing on the deck says, “Hey, I’ve got this life jacket; I don’t know if I can get it out there, but do you want me to throw it to you?”

“That’s kind of what we do with patients when they have advanced-stage cancer and we’ve got a treatment that works sometimes, but not all the time,” he said. “We say to them, ‘You tell us whether you want it or not.’ Of course they’re going to say ‘yes’—unless they have a better feel of the whys and wherefores.”

Dr. David Potter, an oncologist at Enloe who also oversees the medical center’s hospice service, noted: “There are very strong forces in our economy that may be driving the choice to do treatment over not doing treatment. … There’s the idea out there that I just need to go to the right place and get the right drug, and anything can be cured.

“In cancer, sometimes we’re just not sure. So there’s both the uncertainty and the high expectation in our society that technology can solve anything—and maybe it can’t.”

The various decisions that constitute end-of-life planning may boil down to a single pivot point.

“There’s a difference between prolonging your life and quality of life,” said Dr. Samuel Brown, medical director of Enloe’s Supportive and Palliative Care Service. “That discussion has to be had. Some people are thinking, ‘How long can you keep me alive?’—and they don’t look at what price they’re going to pay for that extra week or two, or maybe a month, rather than a much better quality of life in hospice, where they may wind up living as long anyway.”

Still, patients and families struggle with how to proceed. Pat Watters, director of hospice for Feather River, says her staff receives referrals for patients “who are not ready to forego aggressive treatments.” For those individuals, hospice may not be the right option, at least at that time.

“Here at Feather River we have a really good connection with our cancer center,” Watters said, “and our oncologists have really perfected the ability to know when to have that conversation and how to conduct that conversation.”

With Potter bridging oncology and hospice, Enloe is in a similar position to support patients in whichever decision they make. But both hospitals don’t limit their end-of-life-planning initiatives to terminal cancer patients; they’re trying to reach more people early on.

“When we’re talking to people in the hospital,” Potter said, “the train has already left the station.”

One means of planning is completing an advance health-care directive—a comprehensive document that spells out a person’s wishes for a range of medical contingency. There’s also a shorter form known as a POLST (Physician Orders for Life-Sustaining Treatment), which at a glance can tell emergency-medical technicians and physicians what procedures the patient authorizes.

“One of our biggest challenges as a society is we’re not having these conversations,” Brandtman, the case manager, said. “We at Feather River are working very hard with our physicians to make advance decision-making almost an everyday thing.”