Addressing the futility of chemotherapy with patients is challenging for most oncologists. Although defining treatments as “futile” is suitable in the medical literature, it is a word that may carry negative connotations, such as hopelessness or abandonment, to patients. A more descriptive and less negative term, “nonbeneficial,” may be used when discussing futile chemotherapy with patients. The point when chemotherapy becomes nonbeneficial, and thus futile, is different for each patient and might even change over time. Addressing the patient's definition of nonbeneficial chemotherapy regularly during treatment ensures that the patient's goals are clear and allows the oncologist to direct conversation toward alternative options, such as palliative and hospice care, when chemotherapy cannot provide the benefits sought by the patient. This can be as simple as asking the patient, “Do you think the chemotherapy is giving you enough benefit to continue?”
Palliative Care: It's Not Just Giving Up on People
Both the physician and the patient face several decisions when considering whether or not to pursue chemotherapy for advanced cancer. First of all, the patient must decide how much information he or she wants from the oncologist. If the patient is the decision maker, he or she must choose to accept chemotherapy that is palliative, not curative. After a frank discussion about the anticipated outcomes and symptoms associated with chemotherapy, the patient must consider whether he or she can accept the burden of treatment for the potential of prolonging life by days, weeks, or months. On the other hand, the oncologist must decide if chemotherapy should even be offered, based on patient performance status, known therapeutic outcomes, and patient values and goals. The oncologist can reassure patients that the best available data show that patients who use hospice for even one day actually live longer than those who do not.[6] Once informed about what palliative care and hospice offer, the patient may determine whether or not alternatives to chemotherapy are more favorable. If the patient qualifies for clinical trials, he or she must decide to accept treatment with uncertain outcome. When reflecting upon such difficult issues, both the patient and oncologist should involve others to help guide decision making. Oncologists can consult trusted colleagues for their expertise and to ensure that they are using the best information available. Patients should involve loved ones whom they trust to help make decisions in their best interest. Table 1 provides key questions that the oncologist faces when making these decisions and how to approach them.
| Table 1: Questions to discuss with the patient when chemotherapy may be futile | ||
| Question | Leading prompts | Comment |
| What is the patient’s current understanding of the disease? | How much do you know about your cancer at this point?
How much do you want to know? | Be sure the patient is ready to discuss this issue and that you have enough time for discussion.
Ask if there are others who should receive this information simultaneously, afterwards, or instead of the patient. |
| What are the patient’s goals? | Knowing that we can’t cure your cancer, what are your goals, wishes, or hopes for the future? | Treatment decisions may be impacted greatly by a patient’s personal goals (e.g. patient wants to live to child’s graduation, or patient wants to be as comfortable as possible) |
| If chemotherapy is an option and the patient is interested, is he/she aware of potential risks and benefits? | Although everyone responds differently, these are the likely side effects and outcomes of this treatment… | Be specific in terms of likelihood of response, type of response (palliation instead of cure, extent of life prolongation expected, symptom relief, etc.) and how likely it is that treatment will help achieve patient’s goals.
Discuss potential symptom burden from treatment in detail.
Patient needs to be able to make informed decision about risks vs. benefits involved in potential treatment. |
| If the patient declines chemotherapy, treatment is not indicated, or treatment fails, what other options are available? | Let’s talk about options to make sure that you are comfortable and enjoy the highest quality of life possible in the time that you have left. | Focus on pain and symptom management. Discuss hospice options (home vs. inpatient) and make referrals when appropriate.
Stress that you will continue your relationship with the patient (possibly as their hospice provider) and that you will ensure that their symptoms are managed, either directly or through hospice nurses. |