Pastoral support, not life-prolonging care, improves QoL at end of life

By Sarah Guy

Quality of life (QoL) at the end of life (EOL) is improved when advanced cancer patients avoid being hospitalized, when their worry is reduced, they are given pastoral as well as medical care, and when they feel they are in alliance with their physician, show results of the Coping With Cancer (CWC) study.

To date, there is no comprehensive model for the strongest predictors of QoL at EOL, says the research team, but the findings indicate that when medicine is unable to offer patients a cure, physicians may still positively and significantly influence their patients' lives.

The challenge, remark Alan Zonderman and Michele Evans from the National Institutes of Health in Baltimore, Maryland, USA in an invited commentary, is in physicians' and caregivers' ability to develop and maintain effective integrated relationships with their patients that are strong enough to deliver the emotionally difficult messages relevant to prognosis, among other things.

"Physicians are urged to recognize the need for individualized care that will facilitate setting of appropriate treatment goals and end points that focus on QoL, not solely survival at any cost," they remark.

Using CWC data for 396 treatment-refractory advanced cancer patients and their caregivers, Holly Prigerson and colleagues observed that therapeutic alliance ‑ including measures of patients being treated with respect ‑ was among the most important predictors of QoL at the EOL.

They also found that patients who reported engaging in religious prayer or meditation had better QoL (measured using the McGill Quality of Life Questionnaire and DSM-IV) at the EOL (considered as the last week of life, as reported postdeath by caregivers), while dying in hospital, being admitted to the intensive care unit, and high levels of patient worry were among the most significant predictors of worse QoL at EOL.

"Attempts to avoid costly hospitalizations and to encourage transfer of hospitalized patients to home or hospice might improve patient QoL at the EOL," write Prigerson et al in the Archives of Internal Medicine.

The team created a random-effects model of factors associated with QoL at the EOL, and the model with the best predictive accuracy (measured using CV statistic, or mean squared error) showed that 17.7% of the variance in QoL reported by study participants was explained by the factors included.

"Future research with assessments of hospital... and provider... characteristics and more comprehensive, prospective, repeated measures, particularly of therapeutic alliance and QoL is needed," conclude the researchers.

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