Assessing the Impact of Diagnostic Imaging at the End of Life: A Single-Center Retrospective Cohort Study

Objectives: Goals of care discussions allow seriously ill patients to opt out of technology-laden care, which can improve quality of life at the end of life. In a group of patients with metastatic cancer, we sought to document situations where diagnostic testing might have been avoided. Methods: In this single-center retrospective cohort study, we reviewed the medical records of patients with a known diagnosis of metastatic cancer that were hospitalized between January 1st 2012 and December 31st 2012 and underwent a pulmonary angioscan. We documented level of care prescriptions and treatment plans before and after the test postulating that patients who refused anticoagulation despite a diagnosis of pulmonary embolism might have also refused the pulmonary angioscan if goals of care discussions had encompassed diagnostic procedures. Results: We reviewed the charts of 43 patients who met eligibility criteria. Before the pulmonary angioscan, explicit levels of care were documented for 8 patients (19%). This number increased to 25 (58%) after the test. Of 8 documented levels of care before the pulmonary angioscan, 7 were modified to "comfort measures only" after the test. Three of nine patients (33%) with a pulmonary embolism did not receive anticoagulation. In 2 of the 43 patients (5%), documented discussions about end of life preferences encompassed diagnostic procedures. Conclusions: In a population at high risk of death, documented levels of care were infrequent at hospital admission. Having earlier discussions about end of life preferences encompassing diagnostic procedures may reduce unwanted tests at the end of life.