Even with a disease as terrible as cancer, there is hope. Newer drugs and better treatment combinations are helping people survive longer than ever before. But at what point does this hope interfere with good decision-making after therapies fail to work?
As an oncologist at a busy hospital in Richmond, Virginia, Dr. Thomas Smith still faces patients with late-stage cancer who have exhausted all their options. He dreads telling them that there is little he can do to help. Despite all the progress in cancer and the chance that a new drug will maybe add a few months of life, he must explain to some patients that they might be better off spending the rest of their time as comfortable as possible, rather than fighting a battle they can't win.
"Everyone wants a miracle," says Smith, who works at the Massey Cancer Center at Virginia Commonwealth University. Patients tend to be more optimistic about their treatment than doctors, studies show, and often choose aggressive therapy even if there is little chance of benefit. But being open and honest is the only way to help a patient make the best decision about end-of-life care, Smith contends.
"You have to be truthful," he says.
This frankness is what everyone aspires to, but one that seldom happens in practice, according to various studies. Research has shown that doctors overestimate survival by five times as much as what it turns out to be, and many avoid end-of-life discussions all together.
A recent study in the Journal of the American Medical Association highlights what can go wrong from poor communication. A patient who had invasive colon and liver cancer had requested not to be resuscitated if he was in too much pain or would be stuck in a vegetative state. But after a risky surgical procedure, the man started to falter, and needed to have a breathing tube inserted to keep him alive. The family and doctors were left unprepared for what to do next.
"In one of the most horrendous experiences [I had] as a physician, he [the patient] kept trying to pull the tube out, saying he was in a great deal of pain," the doctor explained. Had he been more up front about the slim chances of success from the procedure, the doctor said that the situation might have been avoided.
The urge to fight is understandable, and patients can enter clinical trials when standard treatments fail to work. Yet there is still the tragic reality of cancer, and Smith fears that the consequences of false hope are often overlooked. "Patients are likely to die in a hospital when they could be taking advantage of symptom control," he says
Oncology groups say that hospices are better suited for patients who are expected to live only a few months, where the surroundings are more like home than a hospital, and the emphasis is on relieving pain. There are no defined rules on when to seek end-of-life care, but the topic, Smith and others say, should begin with an honest discussion about a patient's prognosis.
Smith first asks patients if they want to know the full details of their illness. Then he tries to help set goals on what they want from end-of-life care. Expressing one's wishes about when to receive hospice care—or whether to be resuscitated or not—is something that patients, families and doctors should talk about openly together.
"Instead of going through chemotherapy they can concentrate on enjoying life," says Smith.