Clinicians Digest Sept/Oct 2008 - Page 3

End-of-Life Decisions

Although doctors today are trained to communicate better with patients and families than they used to be, when it comes to announcing end-stage cancer diagnoses and discussing treatment options, that training often slips away. Now an article in the June 11 Journal of the American Medical Association by physicians Sarah Harrington and Thomas Smith, palliative specialists at the Massey Cancer Center of Virginia Commonwealth University, describes why it's so difficult to help patients and families confront the emotional issues they must face in handling the end stage of cancer and deciding whether to continue chemotherapy.

The dreadful calculus of balancing the expensive and debilitating effects of further chemotherapy against a limited number of extra days it can afford often leads oncologists, patients, and families to collude in denial. Harrington and Smith say that only about 39 percent of oncologists clearly discuss a terminal prognosis with patients, and even when they do, about a third of patients and families still believe the cancer is curable. "Most people want to maintain hope," says Evan Imber-Black, Director of the Center for Families and Health at New York City's Ackerman Institute, "and many doctors are concerned about saying something that will destroy that hope."

To help doctors, terminal patients, and families over this hurdle, Harrington and Smith present discussion guidelines for this situation. Ask patients their goals; a few extra months may be critical to some people and unimportant to others. Everyone should clearly understand the difference between response and cure; desperate people can easily mistake a 20 percent chance of response with a 20 percent chance of cure. Physicians should bring up hospice as an option, because many people still don't know that hospice usually makes the end stage of life more comfortable than chemotherapy does.

Patients and families often report that once they announce a decision to suspend chemotherapy, their oncologist never shows up again. "Doctors don't recognize that after treatment's ended, they're still tremendously important to their patients," says Massachusetts General Hospital physician Katharine Treadway, who trains medical students in communicating with patients. "Their continued presence means something. Sometimes just bearing witness is the highest kind of caretaking."

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