Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review.
Lauren T Starr, Connie M Ulrich, Kristin L Corey and 1 others
PMID 31072109WHAT IT FOUND
In advanced cancer, goals-of-care talks were linked with less ICU and hospital care near death, more hospice use, and dying outside hospital.
Earlier talks showed stronger links. Cost evidence was limited.
Key findings
01End-of-life discussions were associated with lower odds of acute or intensive care near death and higher odds of hospice use.
02Discussions occurring 30 or more days before death were associated with lower odds of aggressive, acute, or intensive care and higher hospice use.
03Only three studies measured costs. In one randomized trial, patients who received the discussion program and died had median 30-day costs of $1,048 versus $23,482, but total costs fifteen months after randomization were $86,025 versus $111,958 and not significant.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Most included studies were observational, so they show association, not that a conversation caused less aggressive care or lower costs. Only three studies measured costs, and only one was a randomized trial, so the cost finding is narrow. Studies defined end-of-life discussions differently, including self-report, chart documentation, advance directives, POLST, or DNR/DNI orders, so results are not directly comparable. Studies measured utilization differently, including ICU care, hospitalization, emergency visits, length of stay, and chemotherapy, and some grouped outcomes under aggressive care. Six studies did not account for confounders, which could explain part of the associations. Two studies had small samples, so power was limited. Self-report studies could have recall bias, and chart-based studies could miss undocumented conversations. Results were from United States patients with advanced cancer, so they may not apply to other healthcare systems or earlier-stage cancer.
The easy way to misread this
Do not read this as proof that goals-of-care discussions caused lower costs or less aggressive care. Most studies were observational, only three measured costs, and studies defined discussions and outcomes differently.