The article by Khatcheressian and colleagues addresses the important topic of futility in chemotherapy use. While extensive previous literature has addressed the use of futile treatment by oncologists, Khatcheressian and coauthors pose interesting perspectives on patient persistence in seeking futile treatment. The authors have eloquently described essential concepts such as nonabandonment, compassionate communication, and the challenge of being honest while preserving hope. As an oncology nurse for the past 30 years, I offer a few reflections in response to the insights of these authors regarding futility.
Don’t Do It Alone
Khatcheressian and his coauthors wisely encourage oncologists to avoid going it alone by seeking peer support and counsel with fellow oncologists. With regard to confronting the dilemmas surrounding futile treatment, oncologists should not do it alone. Family conferences, patient discussions related to treatment, and conversations regarding hospice are inherently intense and emotionally draining, and both the patient and physician will benefit from interdisciplinary support.
Conversations regarding treatment futility challenge the core of the patient, family, and oncologist as humans, evoking deep reflection on the meaning and sanctity of life and the delicate balance of benefit and harm. Oncologists should enter these conversations with the support of social workers, psychologists, nurses, and chaplains. Whether chemotherapy is initiated or declined, neither patient nor oncologist should feel abandoned in the process.
Futility Through the Lens of Culture
An issue of emerging importance in our increasingly diverse society is the influence of culture on a patient’s decision-making. Khatcheressian and coauthors describe individual variations in understanding the concept of futility. I would add to this discussion the immense influence of culture and religion on chemotherapy and other treatment decisions. A 20- to 60-minute discussion between an oncologist and a patient newly diagnosed with life-threatening disease is a minuscule conversation when weighed against a lifetime of family values, traditions, culturally held beliefs, and deeply entrenched religious beliefs.
The answer to the question “Do you want to try chemotherapy?” is often profoundly influenced by these spiritual or cultural beliefs. Demands for futile care are often expressions of intense beliefs about faith in God or a higher being, the terror of giving up hope, avoiding the pain of a spouse’s or child’s response to the decision, and most importantly, the enormous burden of saying no.
The question about administering chemotherapy thought to be futile must be answered while keeping in mind a fundamental premise—that our obligation is to deliver the greatest good with the least harm. That care is contingent on decisions that respect the patient as a person in the context of diverse cultures and lives.
Palliative Care as Integral to Quality Oncology Care
When I began my career in oncology in 1977 there were fewer than 10 hospice programs in the United States and no palliative care programs. In 2008, there are over 3,000 hospices in America, and recent statistics from the Center to Advance Palliative Care (CAPC) show that over 70% of hospitals with more than 250 beds have a palliative care program. Thus, the era of patient choice being reduced to either chemotherapy—often futile—or feeling abandoned if treatment is declined should not persist. By today’s standards, quality cancer care cannot exist without the integration of palliative care.
The hospice statistics shared in the paper by Khatcheressian are intolerable and a poor reflection on current practices, a far cry from what any of us would hope for if someone we loved had cancer. Hospice referral in the final days of life, treatments causing immense symptoms and burden in the final week of life, and a reimbursement system that denies hospice during disease-focused therapy will hopefully become as rare as the prevalence of hospice when my career began.
All cancer programs should adopt the national guidelines for palliative care from the National Consensus Project for Palliative Care. We need to work to ensure that cancer programs provide the highest quality palliative care as a component of quality cancer care.
Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.