Trajectories of Suffering in the Last Year of Life Among Patients With a Solid Metastatic Cancer

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  • 1 Lien Centre for Palliative Care,
  • | 2 Program in Health Services and Systems Research, and
  • | 3 Centre for Ageing Research and Education, Duke-NUS Medical School;
  • | 4 National Cancer Centre Singapore; and
  • | 5 Division of Palliative Care, National University Cancer Institute, Singapore.

Background: Reducing suffering at the end of life is important. Doing so requires a comprehensive understanding of the course of suffering for patients with cancer during their last year of life. This study describes trajectories of psychological, spiritual, physical, and functional suffering in the last year of life among patients with a solid metastatic cancer. Patients and Methods: We conducted a prospective cohort study of 600 patients with a solid metastatic cancer between July 2016 and December 2019 in Singapore. We assessed patients’ psychological, spiritual, physical, and functional suffering every 3 months until death. Data from the last year of life of 345 decedents were analyzed. We used group-based multitrajectory modeling to delineate trajectories of suffering during the last year of a patient’s life. Results: We identified 5 trajectories representing suffering: (1) persistently low (47% of the sample); (2) slowly increasing (14%); (3) predominantly spiritual (21%); (4) rapidly increasing (12%); and (5) persistently high (6%). Compared with patients with primary or less education, those with secondary (high school) (odds ratio [OR], 3.49; 95% CI, 1.05–11.59) education were more likely to have rapidly increasing versus persistently low suffering. In multivariable models adjusting for potential confounders, compared with patients with persistently low suffering, those with rapidly increasing suffering had more hospital admissions (β=0.24; 95% CI, 0.00–0.47) and hospital days (β=0.40; 95% CI, 0.04–0.75) during the last year of life. Those with persistently high suffering had more hospital days (β=0.70; 95% CI, 0.23–1.17). Conclusions: The course of suffering during the last year of life among patients with cancer is variable and related to patients’ hospitalizations. Understanding this variation can facilitate clinical decisions to minimize suffering and reduce healthcare costs at the end of life.

Submitted October 15, 2020; final revision received December 21, 2020; accepted for publication January 23, 2021. Published online September 7, 2021.

Author contributions: Study concept and design: C. Malhotra. Data acquisition: Finkelstein. Data analysis and interpretation: C. Malhotra, R. Malhotra, Bundoc. Manuscript preparation: C. Malhotra, R. Malhotra, Bundoc. Critical input: Teo, Ozdemir, Chan, Finkelstein. Final approval of manuscript: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This work was supported by funding from Singapore Millennium Foundation (2015-SMF-0003) and Lien Centre for Palliative Care (LCPC-IN14-0003).

Correspondence: Chetna Malhotra, MD, Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore 169857. Email: Chetna.malhotra@duke-nus.edu.sg

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