Oncologist. 2014 Oct 31. pii: theoncologist.2014-0031. [Epub ahead of print]

What Keeps Oncologists From Addressing Palliative Care Early on With Incurable Cancer Patients? An Active Stance Seems Key.

Pfeil TA1, Laryionava K1, Reiter-Theil S1, Hiddemann W1, Winkler EC2.

Author information

• 1Department of Internal Medicine III (Hematology and Oncology), University Hospital Grosshadern, Munich, Germany; Department of Medical Oncology, Program for Ethics and Patient-Oriented Care in Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany; Clinical Ethics, University Hospital Basel, Psychiatric Hospitals of the University Basel, Basel, Switzerland.
• 2Department of Internal Medicine III (Hematology and Oncology), University Hospital Grosshadern, Munich, Germany; Department of Medical Oncology, Program for Ethics and Patient-Oriented Care in Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany; Clinical Ethics, University Hospital Basel, Psychiatric Hospitals of the University Basel, Basel, Switzerland Eva.Winkler@med.uni-heidelberg.de.

Abstract

BACKGROUND:

Sympathetic and frank communication about the terminal nature of advanced cancer is important to improve patients' prognostic understanding and, thereby, to allow for adjustment of treatment intensity to realistic goals; however, decisions against aggressive treatments are often made only when death is imminent. This qualitative study explores the factors that hinder such communication and reconstructs how physicians and nurses in oncology perceive their roles in preparing patients for end-of-life (EOL) decisions.

METHODS:

Qualitative in-depth interviews were conducted with physicians (n = 12) and nurses (n = 6) working at the Department of Hematology/Oncology at the university hospital in Munich, Germany. The data were analyzed using grounded theory methodology and discussed from a medical ethics perspective.

RESULTS:

Oncologists reported patients with unrealistic expectations to be a challenge for EOL communication that is especially prominent in comprehensive cancer centers. Oncologists responded to this challenge quite differently by either proactively trying to facilitate advanced care planning or passively leaving the initiative to address preferences for care at the EOL to the patient. A major impediment to the proactive approach was uncertainty about the right timing for EOL discussions and about the balancing the medical evidence against the physician's own subjective emotional involvement and the patient's wishes.

CONCLUSION:

These findings provide explanations of why EOL communication is often started rather late with cancer patients. For ethical reasons, a proactive stance should be promoted, and oncologists should take on the task of preparing patients for their last phase of life. To do this, more concrete guidance on when to initiate EOL communication is necessary to improve the quality of decision making for advanced cancer patients.