As an alternative to addressing the above issues with the patient independently, oncologists may involve a palliative care specialist to facilitate this conversation.[7] Particularly in cases where the oncologist decides that chemotherapy is no longer a viable option, it may be easier, from both the patient and the provider perspectives, for the palliative care specialist to have this discussion. In a recent survey of patients on our oncology ward, the great majority did not want to discuss advance directives (ADs) with their oncologist—these patients thought ADs were important and should be discussed but were more comfortable discussing them with the admitting provider than the oncologist.[8] Patients may feel that they are disappointing their oncologist by being unable to take further treatment or by admitting that treatment has failed them. Similarly, oncologists might view having this discussion as an admission of their failure as a provider. The palliative care specialist, on the other hand, has no responsibility for chemotherapy and possibly no prior relationship with the patient, thus alleviating this type of emotional association between provider and patient. Furthermore, the conversation about nonbeneficial chemotherapy provides a segue for the palliative care provider to discuss with patients what he or she does best: establishing goals of care, managing symptoms, and maintaining comfort. For the palliative care specialist, providing symptom management and the best possible quality of life for patients are the fundamental goals. Death is generally not viewed with a sense of failure when palliation is the focus of care.
Oncology: Palliative Care Is Giving Up
We still hear from oncologists like ourselves the dreaded words “What do you want me to do, give up on the patient?” or, to the patient, “What, are you giving up? I thought you'd keep fighting!” We would argue that current best practices include knowing when the risks and harms of chemotherapy outweigh any potential chance of benefit. Physicians and patients should follow current National Comprehensive Cancer Network (NCCN) guidelines for solid tumors such as breast9 and lung10 cancer and stop chemotherapy when the chance of success is minimal. If the doctor cannot describe a specific, substantial benefit that outweighs the toxicity, he or she should not recommend it.[11] And all the relevant guidelines call for considering a switch to nonchemotherapy palliative care when the patient's performance status is Eastern Cooperative Oncology Group (ECOG) ≥3, defined as “3 = Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.”[12] Such a simple threshold could dramatically reduce the use of chemotherapy at the end of life and lessen downstream toxicities.
Oncologists can implement several strategies to help facilitate the transition from aggressive care to comfort care (Table 2). For patients with incurable cancer, oncologists can hold early discussions about palliative and hospice options that will need to be implemented when chemotherapy is no longer able to control their disease. This discussion introduces palliative medicine as part of the care plan for incurable disease and allows the patient to anticipate such a transition. Oncologists can also provide reassurance that they will continue to be involved in their patient's care and to support them, even if the patient does not undergo further chemotherapy. There are at least four studies that show equal[13] or better[6] survival, smoother transitions to hospice when death is inevitable, less intensive end-of-life care, and superior patient and family outcomes with concurrent palliative care. [14] and [15] By helping patients establish legal documents, such as ADs and power of attorney, oncologists and palliative care specialists can alleviate some of the stress related to the end of life and make the transition to comfort care easier. Finally, oncologists can review guidelines such as those from the NCCN and American Society of Clinical Oncology, which call for a switch to palliative care when the cancer has grown on three regimens or the patient's ECOG performance status is three or above. [11] and [12]
| Table 2: Things that help ONCOLOGISTS and their patients | ||
| Item | How it helps | Comments |
| Early discussion of palliative and hospice care when chemotherapy may no longer help. | Hospice (and eventual death) will not come as a complete surprise. | “We will do our best to help you with this cancer, but at some point there may not be any treatments known to help….” “Remember the conversation we had when we first met?...” |
| Reassurance that the oncologist will not abandon the patient if concurrent care is given. | This major fear may keep oncology patients at the same practice they have known for years – it is familiar – when they would be better served by transition. | There are now at least 4 randomized trials showing that most patients will accept concurrent palliative care if offered, and that outcomes are equal or better, at less cost.6,13,14,15 |
| Legal documents such as Advance Medical Directives, Durable Medical Power of Attorney | Reinforces the seriousness and “now” aspect of care. | These are readily available in all states at no cost. They are not the final word on how to live one’s remaining time, but will get the conversation started. |
| Best nationally recognized information showing that further chemotherapy will not help due to 3 prior failures, or is not indicated due to poor performance status.9,10 | The oncologist can point to the right page and say “The best national guidelines call for a switch away from chemo…because it will do no good and will cause harmful side effects.” | Readily accessed from the Internet. |
| Use decision aids, similar to Adjuvant!. | Increases the amount of truthful information given, even when the news is bad, and helps with transition points. | An increasing number of these are available[i],[ii],[iii],[iv] and will soon be offered as smart phone applications (aps). |