If patients with terminal cancer are to participate in making good
treatment choices, their physicians must clearly and honestly
communicate both the patients prognoses and the therapeutic
options. This straightforward message from two Virginia Commonwealth
University writers appeared as an editorial in the June 3rd issue of The
Journal of the American Medical Association.
Good End-of-Life Care
"Far too many patients are fighting a battle they cannot win,
and not taking advantage of good end-of-life care," write Thomas
J. Smith, MD, and Karen Swisher, MS, JD, of the Universitys
Medical College of Virginia Hospitals. "While physicians were
reasonably good at predicting who was going to die and when, 82% of
the patients overestimated their survival . . . . Physicians are
obligated to initiate patient dialogue, ask what patients want to
know, provide estimates of survival and the likely effect of therapy,
and discuss all treatment options, including palliative care."
The editorial accompanies a study led by Jane C. Weeks, MD, from the
Dana-Farber Cancer Institute in Boston, which found that patients who
thought that they were going to live for at least 6 months were more
likely to choose aggressive therapy designed to extend life, rather
than palliative care designed to relieve symptoms. Despite aggressive
therapy, patients who overestimated their survival lived no longer
than those who received palliative care. They were more likely than
patients given palliative care to have a hospital readmission,
undergo attempted resuscitation, or die while on a ventilator.
Physicians Reluctant to Admit Failure
The Virginia Commonwealth University editorial authors acknowledged
that some patients refuse to hear what physicians tell them and that
some physicians withhold information in the belief that it will give
patients hope. They also suggested what they consider to be a more
likely explanation for the difference between physician and patient
predictions of life expectancies.
"Physicians find it too uncomfortable to tell patients that they
cannot effectively fight their patients cancer because it means
that clinicians have failed," the editorialists said. "It
is much easier simply to give another round of chemotherapy. Does
this mean that clinicians must sit by the bedside, hold patients by
the hands, and tell them that there is no way to control their
cancer? The answer is yes, when it is the truth. In the same
conversation, physicians should ensure patients that they will not be
abandoned but will be helped to live for as long and as well as they can."
"For now, simply telling patients the truth about their terminal
cancer is a significant step in the right direction," the
writers concluded. "The next [step] should be to study, in
actual practice, how much information is given, how much is received,
and the effects on decision making for those at the end of life."