Patient cognition may affect EOL care intensity

By Sarah Guy, MedWire Reporter

Mild cognitive impairment in patients with advanced cancer may affect the intensity of end-of-life (EOL) treatment and promote decision-making by caregivers, rather than patients, show US study results.

While the findings indicate that patients' preferences for life-extending rather than comfort-giving/ pain relieving care predicted intensive EOL care regardless of cognitive status, caregivers' influence on EOL care increased dramatically with only minor deterioration in patients' cognitive abilities, say researchers.

"As a result, physicians should be more aware of, sensitive to, and probe for possible cognitive impairment in advanced cancer patients, even in cases when cognitive impairment is not obvious, and strive to ensure that all the patients' treatment preferences are sought and respected," they suggest.

Holly Prigerson (Dana-Faber Cancer Institute, Boston, Massachusetts) and colleagues addressed the possible connection between minor cognitive impairment - measured on the Short Portable Mental Status Questionnaire (SPMSQ) - and intensive EOL care in a group of 221 advanced cancer patients and their carers.

The SPMSQ was administered a median 104 days before death, and while the majority (62.9%) of patients had no errors, 24.0% committed one error, 8.6% committed two errors, and 4.5% committed three or four errors, indicating mild cognitive impairment.

The researchers report that, overall, patients with increased impairment were less likely to receive intensive EOL care (odds ratio [OR]=0.56), defined as care in an intensive care unit, use of mechanical ventilation, chemotherapy, tube feeding, or cardiopulmonary resuscitation in the last week of life.

Cognitive impairment modified the association between caregivers' preference for life-extending care and patients' receipt of intensive EOL (OR=6.55), say the researchers. However, cognitive impairment did not affect the chances of receiving intensive EOL care when patients preferred life-extending care (OR=0.40).

Indeed, patient preference for life-extending care predicted intensive EOL care regardless of cognitive status, with a significant adjusted OR of 2.11, report Prigerson et al in the Journal of Pain and Symptom Management.

They found that with each additional error on the SPMSP, the chances of intensive EOL increased a significant near seven-fold (OR=6.90) when caregivers preferred life-extending treatment. Furthermore, when caregivers expressed this preference, patients with two or more SPMSQ errors had a significant adjusted odds of 19.05 for receiving intensive EOL care.

"Overall, these results suggest that the patients, families, and health care providers may want to discuss and document the patients' EOL treatment preferences early in the disease trajectory before cognitive impairment complicates decision making," the authors conclude.

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