Palliative & Supportive Care

Knowledge and attitudes toward end-of-life care in veterans with symptomatic metastatic cancer

SHIRLEY S.  HWANG  R.N., M.S. a1 a2 a3 , VICTOR T.  CHANG  M.D. a1 a4 , JANET  COGSWELL  R.N., M.S.N. a1 a2 , SHANTHI  SRINIVAS  M.D. a1 a4 and BASIL  KASIMIS  M.D. a1 a4
a1 Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, New Jersey
a2 Patient Care Services, VA New Jersey Health Care System, East Orange, New Jersey
a3 University of Medicine and Dentistry of New Jersey, School of Nursing, Newark, New Jersey
a4 University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey

Article author query
hwang ss   [PubMed][Google Scholar] 
chang vt   [PubMed][Google Scholar] 
cogswell j   [PubMed][Google Scholar] 
srinivas s   [PubMed][Google Scholar] 
kasimis b   [PubMed][Google Scholar] 


Objectives: The purposes of this study were to study symptomatic metastatic cancer patients' knowledge and attitudes toward end-of-life (EOL) care and to examine how patient-perceived health status affects attitudes toward EOL care and survival.

Methods: From 1999 to 2002, 254 symptomatic metastatic cancer patients at the VA New Jersey Health Care System completed the Vermont Voices on Care of the Dying Questionnaire. Survival status and location of death were obtained. Descriptive statistics and the chi square method were used to assess the differences between African Americans (N = 109) and Caucasians (N = 135), and between different patient-perceived health status groups. A log-rank test was performed to assess for differences in median survival length between different patient-perceived health-status groups.

Results: Veterans' responses to the Vermont questionnaire showed knowledge deficits regarding EOL care. There was wide variation in self-rankings of health status: 45.6% of patients rated their illness as serious and life threatening, 18.9% considered their health problem significant but not life threatening, 2.8% thought they were in good health, and one-third of patients were unsure about their health status. Most patients (86.2%) preferred physician frankness when communicating bad news and 61.8% preferred family involvement in EOL discussions. African American patients were less likely to have completed advance directives (p < 0.0001), to have knowledge about hospice programs (p < 0.00001), and to feel capable of assessing their health situation (p = 0.04). Patient-rated health status affected completion rates of advance directives and survival.

Significance of the research: These findings demonstrate knowledge deficits and racial differences in attitudes and values toward EOL care in veterans with cancer. The Vermont questionnaire enables patients to state their EOL preferences but may not be detailed enough for clinical applications. Patient-rated health status may be an important explanatory variable for EOL preferences and length of survival.

(Received July 1 2003)
(Accepted September 1 2003)

Key Words: Knowledge; Attitudes and values about end of life care; Survival length; Health status; Racial disparity; Advanced veteran cancer patients.

c1 Corresponding author: Shirley S. Hwang, R.N., M.S., Assistant Professor of Nursing, Section Hematology/Oncology (111), VA New Jersey Health Care System at East Orange, 385 Tremont Avenue, East Orange, NJ 07018. E-mail: