End-of-Life Palliative Chemotherapy: More Harm Than Good?

“We’ve found that patients’ physical and mental state changes as they get closer to death and so too might their preferences regarding the aggressiveness of end-of-life care,” she explained. “We therefore recommend that advance care planning not be a single event but rather repeatedly assessed as the patient’s situation changes. Patients may become cognitively impaired as death approaches, so this further points to the need for a review of patient wishes earlier as opposed to later in the course of illness.”

Conversations should be matter-of-fact and even “blunt”, advised Dr. Prigerson, who conducted doctoral research on end-of-life communication with patients.

“Patients should be told directly that chemotherapy is not intended to cure them and may not benefit them but may result in very aggressive care up until their last breath,” she said. “Vague communication resulted in patients not understanding their prognoses and not planning for their impending deaths.”

Frank communication by oncologists, in contrast, can improve patients’ and family members’ understanding that the patient is terminally ill, she found. “And that led to more proactive and informed decision-making and greater hospice use,” she said.

Many patients do not understand what aggressive end-of-life care really means for the quality of their remaining life.

“They should be made to realize that when you have tubes connected to your nose and mouth that you are unable to communicate with family and friends, are often unconscious, and may not be able to swallow without mechanical assistance,” Dr. Prigerson explained.

“CPR [cardiopulmonary resuscitation] in the hospital is violent and may result in broken bones,” she added, and results in worse quality of life. Patients should be told as much, Dr. Prigerson believes.

“The point isn’t to scare patients, but to paint a realistic picture,” she said.

Patients with cancer and their family members—and their oncologists—“want to believe that chemotherapy may help these patients and may convince themselves that it offers more benefits than it actually does,” she said.

Her team’s findings should increase awareness among physicians “that they may dishonor the Hippocratic oath by offering such patients chemotherapy that does more harm than good.”

References

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3. Silverman R, Smith L, Sundar S. ‘Is it my last Christmas dinner?’ Survival of cancer patients having palliative chemotherapy during Christmas period. BMJ Support Palliat Care. 2014;4(suppl 1):A56.
4. Mannion E, Gilmartin JJ, Donnellan P, et al. Effect of chemotherapy on quality of life in patients with non-small cell lung cancer. Supportive Care Cancer. 2014;22(5):1417-1428.
5. Schnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol. 2012;30(14):1715-1724.