• Mark C Zaros, CurtisJ RandallJR, Maria J Silveira, and Joann G Elmore.
• Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, Washington, USA. mzaros@uw.edu
• J Hosp Med. 2013 Jun 1; 8 (6): 334340334-40.

BackgroundEnd-of-life discussions are associated with decreased use of life-sustaining treatments in patients dying of cancer in the outpatient setting, but little is known about discussions that take place during terminal hospitalizations.ObjectivesTo determine the proportion of patients assessed by the clinical team to have decisional capacity on admission, how many of these patients participated or had a surrogate participate in a discussion about end-of-life care, and whether patient participation was associated with treatments received.DesignRetrospective review.SettingInpatient.PatientsAdult patients with advanced cancer who died in the hospital between January 1, 2004 and December 31, 2007.ResultsOf the 145 inpatients meeting inclusion criteria, 115 patients (79%) were documented to have decisional capacity on admission. Among these patients, 46 (40%) were documented to lose decisional capacity prior to an end-of-life discussion and had the discussion held instead by a surrogate. Patients who had surrogate participation in the end-of-life discussions were more likely to receive mechanical ventilation (56.5% vs 23.2%, P < 0.01), artificial nutrition (45.7% vs 25.0%, P = 0.03), chemotherapy (39.1% vs 5.4%, P <0.01), and intensive care unit (ICU) treatment (56.5% vs 23.2%, P <0.01) compared to patients who participated in discussions. There was no difference between palliative treatments received.ConclusionThe majority of patients with advanced cancer are considered to have decisional capacity at the time of their terminal hospitalization. Many lose decisional capacity before having an end-of-life discussion and have surrogate decision-makers participate in these discussions. These patients received more aggressive life-sustaining treatments prior to death and represent a missed opportunity to improve end-of-life care.Copyright © 2012 Society of Hospital Medicine.

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