Our Future Health: what do we value – resources, quality, or quantity of life?

Our Future Health is a new programme from the RCP, designed to explore the challenges faced by physicians in clinical practice. RCP policy projects and engagement manager Kacey Cogle and clinical fellow Dr Jenny Isherwood explain how longer life expectancy requires patients and the health service to work together in a system with limited resources.

Advances in medical research and improved quality of care means the UK population has a longer life expectancy than ever before.

 However, this also means those diagnosed with chronic diseases are living longer with their conditions, which may significantly impact on their quality of life. In order to create a sustainable health service, we need to understand what we value in healthcare.

This means exploring tensions between increasing length of life versus quality of life, clinical outcomes versus patient experience and individual needs versus population health. As part of the Our Future Health programme of work, the RCP is considering how promoting a shared understanding and measurement of value could improve our use of resources and enable better and more informed decisions about care.

In this month’s Clinical Medicine, RCP president Professor Jane Dacre writes: ‘there is inevitability about death which we do not always recognise in our quest to provide high quality treatments.’ Thinking of this inevitability and the use of scarce and expensive resources, a culture change in the way we discuss and prepare for death, with greater value placed on frank discussions and patient choice is required.

Often patients favour quality over quantity of life, which requires a much less resource intensive management plan. This avenue should be further explored and promoted to prevent unwanted and unnecessary over-medicalisation at the end of life and potentially release resources in an already overburdened NHS.

Consider the issue of chemotherapy in metastatic cancer patients as they near end of life. Metastatic cancer treatment is a complex and ever-changing myriad of toxic medications and therapies designed to prolong, but never save, a life. As research advances, there are more treatment options and, as a result, higher expectations of what this treatment is able to achieve.1 However, metastatic cancer is a terminal illness. Inevitably physicians must be prepared to advise and support their patients to make decisions on whether they value the quality of their remaining life, or extending its length for what could be just a few uncomfortable days or weeks.

In 2013, an Italian study reported that 24% of patients treated with chemotherapy received their last dose within one month of death.2 These proportions are not isolated and have been demonstrated in other studies both nationally and globally. The study acknowledges that age, performance status, tumour sensitivity, survival prognosis and co-morbidities should be considered in decision making around prognosis and end-of-life care.

Further, studies highlighted communication and prognostic difficulties between patients

with physicians because of physicians consistently overestimating survival, by a factor of 5.3. This optimism probably has an impact on patients opting for further available treatment, sometimes with this choice resulting in worse clinical outcomes.1

The study showed that many patients are more likely to choose aggressive treatment for a smaller benefit than initially perceived by their healthcare providers. This could be addressed by clear and honest discussions about prognosis, choices, typical outcomes and decision processes.

The New England Journal of Medicine published a study looking at patients with metastatic non-small-cell lung cancer who were randomly assigned to either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and 12 weeks. The results showed that patients assigned to early palliative care had a better quality of life, fewer depressive symptoms and, surprisingly, a longer median survival rate compared with the control group.3 Early introduction of palliative care led to less aggressive end-of-life care, such as reduced chemotherapy and longer hospice care. Timely introduction of palliative care could, as this study suggests, improve quality of life, and reduce the burden of unnecessary treatment on both the individual, and on an overburdened system, simultaneously.

To gain the most value from the resources available, we as doctors need to work with patients and carers to reduce overuse, unnecessary treatment and waste, and promote a more dignified end-of-life experience through open and, at times, challenging dialogue. Evidence indicates that person-centred care, honest conversations about what matters to those affected and early care planning, often promote better use of resources. However, it’s not enough that physicians take on this burden alone.

The system needs to reflect a cultural change that values palliative treatment options that can improve quality of life as much as therapeutic options. To echo Professor Dacre’s words, ‘our system needs to adapt to ensure that appropriate use of resources, patient experience and health outcomes do not become mutually exclusive’.

References

1 Matsuyama R, Reddy S, Smith TJ. Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol 2006;24(21):3490–6.

2 Pacetti P, Paganini G, Orlandi M et al. Chemotherapy in the last 30 days of life of advanced cancer patients. Supportive Care in Cancer 2015;23(11):3277–3280.

3 Temel JS, Greer JA, Muzikansky A et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Engl J Med 2010;363:733–742.