(worth reading) Impaired Quality of Death Not necessarily a result of toxic and ineffective chemotherapy

Editorial
 
Newspapers in July 2015 were filled with reports about second-line chemotherapy impairing the quality of the last week of life for cancer patients. The basis of the reports was the multicenter CwC1 (Coping with Cancer 1) study that associated impaired quality of death (QOD) with prior administration of second-line chemotherapy.¹ These reports are misleading because although there are many reasons not to administer toxic and ineffective therapy, impaired quality of the last week of life is one of the lesser ones; the relationship between such therapy and impaired QOD likely is an association, not a cause-and-effect relationship.
The authors asked primary caregivers (family member or life partner in about 97% of the cases) within a few weeks after a patient’s death to rate the quality of the last week of the patient’s life. After dividing the responses at the median score, they found more responses below the median among caregivers of patients who had received second-line chemotherapy for a variety of common epithelial cancers.
Rather than being cause and effect, this finding most likely is a result of the association of use of second-line chemotherapy—which in 2002 to 2008, when the study accrued, was largely toxic and ineffective—with an aggressive posture toward aggressive care at the end of life that prolongs suffering and impairs the dignity of both patient and family.

In another report based on the CwC1 cohort, the authors reported an increased frequency of end-of-life hospitalizations and futile interventions, such as resuscitations, mechanical ventilation, and intensive care among patients subjected to second-line chemotherapy.² These futile and unpleasant interventions are likely what caused the impaired QOD, not the ineffective and toxic chemotherapy given months earlier. Although I do not wish to advocate for toxic and ineffective second-line chemotherapy, this therapy given a median of 3.5 months before death is not what impaired the family’s recollection of the patient’s last week. The futile and unpleasant interventions that were chosen by the patients, families, and physicians are what did that!......