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 University’s 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 patient’s 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."
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