J Med Ethics 34:664-668 doi:10.1136/jme.2007.022731
  • Ethics

Decision-making in patients with advanced cancer compared with amyotrophic lateral sclerosis

  1. A B Astrow1,2,3,
  2. J R Sood2,3,
  3. M T Nolan4,
  4. P B Terry4,
  5. L Clawson4,
  6. J Kub4,
  7. M Hughes4,
  8. D P Sulmasy2,3
  1. 1
    Maimonides Medical Center, Brooklyn, New York, USA
  2. 2
    St Vincent’s Hospital Manhattan, New York, New York, USA
  3. 3
    New York Medical College, Valhalla, New York, USA
  4. 4
    The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
  1. Dr D P Sulmasy, Saint Vincent Catholic Medical Centers Manhattan, Department of Ethics, 153 West 11th Street, NR 817, New York, NY 10011, USA; daniel_sulmasy{at}
  • Received 17 August 2007
  • Revised 31 December 2008
  • Accepted 16 January 2008


Aim: Patients with advanced cancer need information about end-of-life treatment options in order to make informed decisions. Clinicians vary in the frequency with which they initiate these discussions.

Patients and methods: As part of a long-term longitudinal study, patients with an expected 2-year survival of less than 50% who had advanced gastrointestinal or lung cancer or amyotrophic lateral sclerosis (ALS) were interviewed. Each patient’s medical record was reviewed at enrollment and at 3 months for evidence of the discussion of patient wishes concerning ventilator support, artificial nutrition and hydration (ANH), resuscitation (DNR) and hospice care. A Kaplan–Meier analysis was also performed and 2-year survival calculated.

Results: 60 cancer and 32 ALS patients were enrolled. ALS patients were more likely than cancer patients to have evidence of discussion about their wishes for ventilator support (31% vs 0%, p<0.001), ANH (38% vs 0%, p<0.001), DNR (25% vs 0%, p<0.001) and hospice care (22% vs 5%, p = 0.03). At 6 months, 91% of ALS patients were alive compared with 62% of cancer patients; at 2 years, 63% of ALS patients were alive compared with 23% of cancer patients (p<0.001).

Conclusions: Cancer patients were less likely than ALS patients to have had documented advanced care planning discussions despite worse survival. This may reflect perceptions that ALS has a more predictable course, that advanced cancer has a greater number of treatment options, or differing views about hope. Nevertheless, cancer patients may be less adequately prepared for end-of-life decision-making.


  • Competing interests: None.

  • Funding: This study was funded by the National Institute of Nursing Research at the National Institutes of Health (1 R01 NR005224-01A1), by a grant from the Leslie R Samuels and Fan Fox Foundation (administered by the Partnership for Caring) and by the ALS Research Center of the Johns Hopkins University

  • Ethics approval: The study was approved by the institutional review boards at the Johns Hopkins Medical Institutions in Baltimore, Maryland and St Vincent’s Hospital Manhattan.