Decision-making in patients with advanced cancer compared with amyotrophic lateral sclerosis.

AIM: Patients with advanced cancer need information about end-of-life treatment options in order to make informed decisions. Clinicians vary in the frequency with which they initiate these discussions. PATIENTS AND METHODS: As part of a long-term longitudinal study, patients with an expected 2-year survival of less than 50% who had advanced gastrointestinal or lung cancer or amyotrophic lateral sclerosis (ALS) were interviewed. Each patient's medical record was reviewed at enrollment and at 3 months for evidence of the discussion of patient wishes concerning ventilator support, artificial nutrition and hydration (ANH), resuscitation (DNR) and hospice care. A Kaplan-Meier analysis was also performed and 2-year survival calculated. RESULTS: 60 cancer and 32 ALS patients were enrolled. ALS patients were more likely than cancer patients to have evidence of discussion about their wishes for ventilator support (31% vs 0%, p<0.001), ANH (38% vs 0%, p<0.001), DNR (25% vs 0%, p<0.001) and hospice care (22% vs 5%, p = 0.03). At 6 months, 91% of ALS patients were alive compared with 62% of cancer patients; at 2 years, 63% of ALS patients were alive compared with 23% of cancer patients (p<0.001). CONCLUSIONS: Cancer patients were less likely than ALS patients to have had documented advanced care planning discussions despite worse survival. This may reflect perceptions that ALS has a more predictable course, that advanced cancer has a greater number of treatment options, or differing views about hope. Nevertheless, cancer patients may be less adequately prepared for end-of-life decision-making.

Physicians' confidence in discussing do not resuscitate orders with patients and surrogates.

PURPOSE: Physicians are often reluctant to discuss "Do Not Resuscitate" (DNR) orders with patients. Although perceived self-efficacy (confidence) is a known prerequisite for behavioural change, little is understood about the confidence of physicians regarding DNR discussions. SUBJECTS AND METHODS: A survey of 217 internal medicine attendings and 132 housestaff at two teaching hospitals about their attitudes and confidence regarding DNR discussions. RESULTS: Participants were significantly less confident about their ability to discuss DNR orders than to discuss consent for medical procedures (p<0.001), and this was true for both attendings (p = 0.002) and housestaff (p<0.001). In a multivariate logistic model of confidence regarding DNR discussions, women were less confident than men (OR = 0.52, CI = 0.29 to 0.92); house officers were less confident than attendings (OR = 0.35, CI = 0.20 to 0.61), those who were less confident of their ability to discuss medical procedures were less confident discussing DNR (OR = 0.12, CI = 0.06 to 0.25), and those who found talking to patients about DNR orders very difficult reported less confidence than those who did not (OR = 0.06, CI = 0.02 to 0.16). CONCLUSION: We conclude that physicians' confidence regarding DNR discussions is low compared with their confidence regarding other medical discussions and that confidence varies by sex and perceived difficulty of the task. Efforts to improve DNR discussions should explore the need to tailor educational interventions to fit these characteristics.