Leaders of the American Society of Clinical Oncology (ASCO) discussed
the societys comprehensive position statement calling for the
removal of all barriers to high-quality end-of-life care. ASCOs
recommendations include greatly expanded access to care, more
intensive physician training, and increased research attention to the
problem. The statement was discussed during a special Presidential
Symposium at the societys 34th Annual Meeting and was published
in the Journal of Clinical Oncology.
The statement, entitled "Cancer Care During the Last Phase of
Life," developed over the last year by a 20-member panel of
oncologists and other cancer professionals, identifies the leading
barriers to providing high-quality end-of-life care and the specific
steps needed to improve care for the nearly 50% of cancer patients
who do not survive the disease.
The statement does not take an official position on
physician-assisted suicide, citing widely varying beliefs in the
professional community and among the public. ASCO stresses that
physician-assisted suicide remains an extremely rare event, and often
results from inadequate pain control or depression--symptoms that can
and should be relieved through better palliative care and
ASCO also released the results of a nationwide survey of physician
practices in caring for terminally ill cancer patients. The survey of
3,200 oncologists addressed topics ranging from pain management to
"Most people when nearing death want empathetic care that
preserves their dignity," said Dr. Robert J. Mayer, president of
ASCO, who has made improved end-of-life care a major focus of his
presidency. "It is oncologists professional responsibility
to care for patients from diagnosis throughout the course of illness,
including the last phase of life. Better physician education, greatly
expanded research on end-of-life care, and relief from the economic
burden of caring for the terminally ill must be aggressively addressed."
Barriers to High-Quality End-of-Life Care
The ASCO position statement identifies the most significant obstacles
to improving end-of-life care of cancer patients, and proposes a
series of remedies:
1. Remove economic barriers.
Reform national health care policies to ensure the availability of
technically expert and humane end-of-life care for all Americans.
Improve the reimbursement policies of public and private insurers to
eliminate the disincentives to physicians to make timely referrals of
patients to hospice and other forms of end-of-life care.
Adequately cover the costs of end-of-life care--especially pain
medications--without onerous copayment arrangements. (For example, a
20% copayment on $4,000 per month for at-home continuous infusion
morphine is highly prohibitive.)
2. Physician-assisted suicide is infrequent; points to inadequate
The ASCO statement neither supports nor condemns physician-assisted
suicide, calling the practice a "complex and subtle issue,"
which "for the time being must be resolved on a case-by-case
basis between the patient and the physician and existing law."
Because of its infrequency, and widely varying beliefs in the
professional community and among the public, ASCO feels that the most
important response to the public debate over physician-assisted
suicide is threefold:
Take every responsible measure to ensure that all physicians are
well-trained in optimal end-of-life care, including symptom
management and psychosocial issues.
Educate the public about their options for end-of-life care.
Remove all barriers to the delivery of optimal end-of-life care.
3. Better educate physicians.
Inappropriate attitudes of physicians toward death, poor
doctor-patient communication, and the insistence on active
anti-cancer treatment beyond its usefulness by some physicians, pose
significant barriers to effective care.
Education of physicians and other health care providers must be
improved through training programs and formal curricula in the
Recognition when anticancer therapy will not help
Techniques of palliative care
Effective communication with the patient/family
Ethical issues that arise during end-of-life care
Teaching of leadership skills to physicians in order for them to
direct the team of end-of-life care.
4. Greatly expand investigative efforts into physical,
psychological and socioeconomic issues.
Research into the many aspects of end-of-life care is virtually
nonexistent, and is urgently needed in the areas of:
Depression and other mental health symptoms
Impact of spirituality
Communication--how to talk truthfully to patients and their families
about illness, treatment possibilities, prognosis, and advanced care
planning, without removing hope
5. Expand and support hospice programs.
Hospice--where terminally ill patients are provided with expert,
comprehensive end-of-life care at home or in a home-like setting--is
the best developed model for end-of-life care in the US health care
system but remains severely underutilized. The most significant
barriers to increased use of hospice include nonreferral by the
primary physician, late referral, and ineffective collaboration
between the physician and hospice.
Physicians must better recognize when anticancer therapy will no
longer be effective and more assiduously pursue a discussion of
end-of-life care options (hospice) with patients. Physicians must
also be more willing to relinquish or share authority in a
patients care to hospice programs, and to ensure that patients
are referred in a timely manner, when palliation will be most effective.