Clinical Studies
Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer

An earlier version of this report was presented at the meeting of the Society of General Internal Medicine, May 2–4, 1996, Washington, DC.
https://doi.org/10.1016/S0002-9343(98)00242-3Get rights and content

Abstract

Purpose: To describe characteristics, outcomes, and decision making in patients with colorectal cancer metastatic to the liver, and to examine the relationship of doctor-patient communication with patient understanding of prognosis and physician understanding of patients’ treatment preferences.

Patients and Methods: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was a prospective cohort study conducted at five teaching hospitals in the United States between 1989 and 1994. Participants in this study were hospitalized patients 18 years of age or older with known liver metastases who had been diagnosed with colorectal cancer at least 1 month earlier. Data were collected by patient interview and chart review at study entry; patients were inteviewed again at 2 and 6 months. Data collected by physician interview included estimates of survival and impressions of patients’ preferences for cardiopulmonary resuscitation (CPR). Patients and physicians were also asked about discussions about prognosis and resuscitation preferences.

Results: We studied 520 patients with metastatic colorectal cancer (median age 64, 56% male, 80% white, 2-month survival 78%, 6-month survival 56%). Quality of life (62% “good” to “excellent”) and functional status (median number of disabilities = 0) were high at study entry and remained so among interviewed survivors at 2 and 6 months. Of 339 patients with available information, 212 (63%) of 339 wanted CPR in the event of a cardiopulmonary arrest. Factors independently associated with preference for resuscitation included younger age, better quality of life, absence of lung metastases, and greater patient estimate of 2-month prognosis. Of the patients who preferred not to receive CPR, less than half had a do-not-resuscitate note or order written. Patients’ self-assessed prognoses were less accurate than those of their physicians. Physicians incorrectly identified patient CPR preferences in 30% of cases. Neither patient prognostication nor physician understanding of preferences were significantly better when discussions were reported between doctors and patients.

Conclusions: A majority of patients with colorectal cancer have preferences regarding end of life care. The substantial misunderstanding between patients and their physicians about prognosis and treatment preferences appears not to be improved by direct communication. Future research focused on enhancing the effectiveness of communication between patients and physicians about end of life issues is needed.

Section snippets

Patient population

The data in this study were collected as part of SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. SUPPORT investigators collected information on patient, doctor, and surrogate decision making in seriously ill patients at five academic acute care teaching hospitals: Beth Israel Hospital in Boston, Massachusetts; MetroHealth Medical Center in Cleveland, Ohio; Duke University Medical Center in Durham, North Carolina; St. Joseph’s Hospital in

Description of study population

A total of 520 patients with colorectal cancer were enrolled in SUPPORT (Table 1). The median age was 64 at study entry (interquartile range 56 to 71) and the median years of education was 12 (interquartile range 11 to 14). Eighty-five percent were white, 9% black, and 4% were Hispanic.

Most of the patients (96%) had received at least one cancer therapy. While the selection criteria required only the presence of a single liver metastasis, 57% had additional liver, lung, or pleural metastases.

Discussion

Among patients with metastatic colorectal cancer, almost 2 in 5 of those with a preference did not want CPR. Factors independently associated with this choice included older age, worse quality of life, presence of lung metastases, and a perception of a worse prognosis. All four of these factors were associated with higher mortality at 2 months, and may indicate that patient prognosis is the chief influence on decisions about CPR.

Of the patients who preferred not to have CPR, more than half did

Acknowledgements

The authors wish to thank Jane Soukup, MS, for assistance in data management, Erin Hartman, MS, for editorial support, and Candance Fifer for support in preparation of the manuscript.

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    Supported by the Robert Wood Johnson Foundation. The opinions and findings contained herein are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or their Board of Trustees. Dr. Haidet was supported in part by National Research Service Award No. PE11001-09.

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