Some patients refuse to stop chemo at end of life
Physicians must guide patients
"Dr. O: 'I couldn't get him to stop thinking that he needed one more treatment. One more treatment was what he needed to spring him loose.'"1
The above quote from an article published in the Journal of the American Medical Association (JAMA) in June demonstrates the challenges that physicians can have with certain patients who, in everyday language, refuse to give up the fight to continue with their life, even if a prognosis suggests that is not possible.
In the case described in the JAMA article, which is titled "The Role of Chemotherapy at the End of Life: 'When Is Enough, Enough?'" the patient underwent chemotherapy treatment a mere six days before his death. That begs the question of when should a patient seek hospice, and how can physicians aid in a patient's acceptance of a negative prognosis.
As baby boomers age and more people approach the end of life, there will likely be more people who choose the approach of fighting their disease past the point where they perhaps would have been better served to enter hospice — both for their own comfort and their families.
Part of the dilemma lies in the fact that chemotherapy is more available than in the past.
"As chemotherapy is increasingly available, and better tolerated, its use at life's end involves so-called sophisticated oncological assessment assessment, a focus on the patient's goals of care, and a balancing of perspectives of the patient and treating oncologist," the article states.
When considering treatment options —and potential outcomes — the article's authors, Sarah Elizabeth Harrington, MD, and Thomas J. Smith, MD, offer a series of questions for patients to ask. The authors are both of Virginia Commonwealth University.
They wrote that, "This can be provided to the patient in the waiting room for discussion with his or her physician."1 (See box.)
Still, as the article also notes, "It is critical to understand that people looking death in the eye have a different perspective."1
Struggle to deliver prognosis
According to J. Vincent Guss Jr., MDiv., chaplain, Falcon's Landing Air Force Retired Officers Community in Potomac Falls, VA, "There are definitely [physicians] who have a difficult time . . theirs have a much easier time. On one level, it's never easy, because physicians are human and no one wants to communicate news that's perceived as bad."
Guss says that often, the reasons some physicians may have difficulty is that for them, a negative prognosis "represents a failure — a personal failure and a failure of science."
"They see death as the last illness to be cured, and it's incurable," he says.
Then, there are those physicians who either have some type of training relative to end-of-life care or "who are simply gifted within themselves" to be able to deliver bad news in a compassionate and sensitive manner — even when there is no chance of a cure or recovery.
However, with more and more medical schools focusing on the humanities and the "spiritual dimensions" of health care in their programs, physicians are getting better at being the bearers of news that's hard for most patients to receive.
Many more now understand, too, as a result of such training, that "death is sometimes to be embraced and how to communicate that . . . when there is no other alternative than palliative or comfort care," says Guss.
Physicians, he said, need to be trained not only medically but also in such areas as psychology.
"It's a holistic approach," he says.
Advice for physicians
According to the article by Harrington and Smith, in their experience, "many families who choose . . . to enroll in hospice with they had done so sooner." And Guss's experience confirms that, he says.
Therein lies the challenge for certain physicians.
Guss recommends a team approach to end-of-life care, involving the patient, family, physicians, nurses, social workers, and any clergy offering comfort.
While, as chaplain, his primary obligation is to the patient, he also takes a team approach. He advises against giving "mixed messages," but to take an approach "that's clear, but very sensitive."
One of the primary concerns —and goals of the team approach —is to let the patient know that he or she is not alone.
Hospice a benefit
One way to introduce compassionate care is to introduce hospice, which some patients resist. He suggests not introducing hospice as a way of "giving up," but rather, "'This is the care that is indicated.'"
"And it's medical treatment, but a treatment to bring dignity and care in the real meaning of care for the patient and family."
Reference
Harrington SE, Smith TJ. The role of chemotherapy at the end of life: When is enough, enough? JAMA 2008; 299(22): 2,667-2,678.
Sources
For more information, contact:
- J. Vincent Guss Jr., MDiv., Chaplain, Falcons Landing Air Force Retired Officers Community, Potomac Falls, VA. E-mail: [email protected].
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