Aggressive treatment at the end of life is in the news again. Narang et al1 recently published a study in JAMA Oncology that suggests that many patients with cancer are still receiving aggressive treatment at the end of life, despite efforts in advanced directives, symptom management, and initiatives such as ASCO's Choosing Wisely campaign. In fact, the investigators saw no improvement compared with 10 or 15 years ago.
As an oncologist who cares for patients with pancreatic cancer, I'm all too familiar with the scenario. My patients come to me for treatments that will prolong their lives. Very few have a chance for cure, but they know that if they live longer, more options may become available. Maybe someone will find the magic bullet that will put them into a durable remission. Why shouldn't they hope for that? I do, too!
Unfortunately, reality is different. After 1 or 2—sometimes even 3—lines of treatment, I'm often faced with the hard and complicated task of explaining to my patients how more treatment is only likely to harm them. I must explain that avoiding active treatment and focusing on symptom management might even prolong their life. Sometimes, my patients know this. They are tired of trying and relieved that they can spend some precious time living without the interruption of trips to the infusion center or radiology for imaging studies.
For the most part, families support the patient's decision to stop therapy. So sadly, we say our goodbyes. Oddly enough, many patients thank me for what I have tried to do, even though I don't feel I deserve thanks. I praise them for their hard work and inspiration. And then, hospice comes in quietly to ease their transition to death.
But sometimes—too often—patients don't want to “give up.” Sometimes even the patients who are personally willing to do so feel they must fight on for the sake of their loved ones. These are the patients who seek many opinions and pursue unproven alternative therapies or travel long distances to access investigational drugs. They want to leave no stone unturned. There must be a cure out there somewhere….
So I can imagine what takes place in a busy practice. How it might be easier to offer more treatment than to spend time, sometimes a lot of time, trying to educate these patients and their families. But I also wonder how I would act if I was in their shoes. So often patients have heard stories of doctors who weren't up to date with advances or of new drugs approved that, almost overnight, transformed lives. Sadly, some practitioners knowingly or unknowingly offer expensive unapproved therapies, with the promise of cures. Common sense doesn't always rule when you are facing death.
I don't know quite how we'll get out of this, but I know we must keep trying. Education for providers and patients will help. I suspect third party payers will also get more involved. After all, aggressive end-of-life care is costly. But let us never lose our sensitivity about the issues our patients face. After all, it could be our turn next.
NarangAKWrightAANicholasLH. Trends in advance care planning in patients with cancer: results from a national longitudinal survey. JAMA Oncol2015;1:601–608.