A dose of Honesty Is Good Medicine: When to Say, No more Chemo

Understandably, oncologists are reluctant to tell patients that there is no longer any benefit for them to continue chemotherapy. It is a conversation that alters the doctor/patient relationship, an acknowledgement by the doctor that, despite all the advances of modern medicine, “I can do nothing more to extend your life.” However, according to ongoing research, this difficult conversation is not being had enough, and patients, clinging to false hope, are being given chemotherapy when it should have been discontinued in favor of palliative care. 

A study by Murillo and Koeller in The Oncologist [2006; 11:1095–1099] looked at chemotherapy given near the end of life to advanced non-small cell lung cancer (NSCLC) patients treated in the community oncology setting. The results are telling:

The researchers reported data from 10 community practices including 417 patients treated for advanced NSCLC in 2000–2003. The mean age was 67 years (median, 62 years) and 54% were male. Forty % of patients were >69 years of age and 35% had an ECOG PS of ≥2. First-line chemotherapy included combination therapy in 84% of patients. Second-line therapy was given to 56% of patients; 26% of patients received third-line therapy, while 10% received fourth-line therapy and 5% received fifth-line therapy or greater. Patients received a mean of 6.1 cycles of chemotherapy. For patients receiving chemotherapy at the time of death, the mean line of therapy being given was second line. Chemotherapy was given within 1 month and 2 weeks of death to 43% and 20% of patients, respectively.

Conclusion: The availability of new chemotherapeutic agents has caused a subsequent increase in the length of time patients are receiving chemotherapy with advanced NSCLC. This would suggest an increased use of chemotherapy near the end of life, which was identified in this study.

Studies also suggest that the struggle to engage in honest, goal-oriented conversation when curative or maintenance therapy is no longer clinically feasible, is partly driven by the patient’s wish to ‘try anything at all’ in order to extend life. Further exacerbating the initiation of honest discussion about end-of-life issues is a semantic dilemma, choosing the proper terms and language oftentimes becomes an emotional chess game of avoidance. The patient wants their physician to deliver positive news and, by turns, the physician wants to delay what might be a hope-crushing discussion of prognosis. The result is a delay in beneficial treatment opportunities such as hospice care, generally regarded as the gold standard when death is imminent. However, the ‘hospice’ word is still a word used tentatively among oncologists.

Case in point, in an editorial in the Journal of Supportive Oncology, [Support Oncol 2008;6:322] Paul R. Helft, MD, Associate Professor of Medicine at the Indiana University School of Medicine, wrote: “In practice, I almost never use the naked word hospice, especially when I first introduce it. This word conjures various images in patients’ minds, many of them inaccurate. Some people imagine a place where you go to die; others believe it to be the last step, the final stage, the end. To some, hospice also suggests giving up. However, all practitioners who refer many patients to hospice do so in the belief that these programs provide the best, highest quality, and most efficient and effective means of supporting the palliative and end-of-life needs for dying patients.”

In a corresponding commentary to Dr. Helft’s editorial, Lidia Schapira, MD, Assistant Professor, Department of Medicine, Harvard Medical School, said, “Hospice by any other name remains a venue for delivery of nursing and social services for dying patients. If changing the name to a more inclusive term, such as hospice home nursing program, makes it easier to introduce the topic, I am in favor of such a modification. But if is intended to soften the blow, I am not so enthusiastic. As a conversation starter, such a change may be useful. But the opener must be followed by a main course: clinicians must have another talk with patients to explain the details of hospice and to fully articulate and flesh out what end-of-life care entails. If not, patients remain at risk for overhearing the bad news from strangers.”

Talking about death is not easy. For oncologists it is a dreaded and often inevitable outcome. As a medial culture, we shy away from mortality issues. Tenacity and positivity in the face of desperate clinical scenarios are vital qualities in an oncologist treating people with cancer. But so is honesty, given out in the proper doses on a patient-by-patient basis.

Look here for more on this important topic: interviews and podcasts with today’s leaders in palliative and end-of-life care…