EMU Today

YPSILANTI – “I didn’t go into medicine to help people die.”

It’s one of the toughest decisions a physician can make – whether and when to stop chemotherapy treatment for a patient with advanced incurable cancer.

Such end of life decisions are interwoven with emotional demands and other distinct psychological challenges that can lead to prescribing chemotherapy late in the disease course, even when it is not expected to help and may actually worsen a patient’s condition, concludes lead author and Eastern Michigan University professor Minnie Bluhm, along with her co-authors, in a recently published study.

Dr. Bluhm, a professor of health sciences in the College of Health and Human Services, conducted 17 in-depth interviews with oncologists to illuminate their rationales for offering late chemotherapy to patients who have incurable cancer and are near the end of life. While the study sample was drawn from the Midwest, participants reflected the general population of U.S. oncologists with respect to age, gender and ethnicity.

Bluhm et al. note that clinical factors take priority in determining late chemotherapy decisions when there are clear treatment options. For example, an otherwise healthy patient with a cancer that is responsive to chemotherapy is likely to be treated. However, emotion becomes an important factor when the clinical factors become ambiguous.

“Oncologists experience unique and difficult challenges when caring for dying patients, including emotionally draining communication, overwhelming responsibility for a patient’s life or death, the limitations of oncology to heal, and uncertain prognosis,” Bluhm said. “These challenges can be eased by offering late chemotherapy.”

Among the factors influencing oncologists’ decisions:

• Patient wishes for treatment.Patient preferences regarding treatment were the most frequently and emphatically reported factor to influence chemotherapy decisions. Oncologists reported offering late chemotherapy to patients with incurable cancer even when they do not expect it to help the cancer or other physical symptoms, because it palliates emotional distress and maintains patient hope. As one participant said, “If the patient tells you, ‘Just give me a chance, treat me with something.’ it’s very hard to say no.“

• Communication about stopping or not starting chemotherapy.For many respondents, telling patients they have no further treatment to offer is one of their most difficult tasks. Such a discussion was characterized as “stomach turning,” “emotionally draining,” and “horribly sad.” Moreover, some reported that it’s easier to bypass this talk and instead just offer the next round of chemotherapy.

•Limitations of oncology to heal.  Respondents reported feeling badly when they had no effective treatments left to offer, noting that they are trained to act or do something for their patients. “I didn’t go into medicine to help people die,” one respondent remarked.

Other illuminating statements made by oncologists about late chemotherapy decision making:

“I know a colleague who treats to the grave and I think he tries to have these conversations with patients about end of life, but he always wants to present some hope, because you do. You want to balance reality with hope, and I think in his case, it always comes out in such a way that people choose the hope side and go home with a prescription.”

“It’s pretty emotional, it’s pretty intense in the room. You can kind of feel the heaviness, and it almost feels like every time you do this, a ton of bricks has fallen on top of you.”

“I wish I had been able to say, ‘Let’s not pursue chemotherapy,’ but at the same time it was just that, ‘What if? What if? What if? What if?’”

Bluhm said such powerful statements spotlight the paradox of late chemotherapy by revealing a nuanced understanding of why it can be so difficult for oncologists to refuse to offer it.

What’s needed?

Bluhm et al. cite the need for further work that explores the impact of these decisions on oncologists themselves, particularly as they take place in the context of a culture focused on cure and broader societal norms of death denial. Larger-scale studies building on these findings are needed, as late chemotherapy imposes costs to patients and society that cannot be ignored.

“Optimal end of life treatment decisions require supportive interventions and system change, both of which must take into account the challenges oncologists face.” Bluhm says.

Citation: Bluhm M, Connell CM, De Vries RG, Janz, NK, Bickel, KE, and Silveira, MJ: Paradox of prescribing late chemotherapy: Oncologists explain. Journal of Oncology Practice  10.1200/JOP.2016.013995

About Eastern Michigan University

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