Cancer and Endof Life Care

In the past oncologists typically greeted with foreboding and mistrust the prospect of relinquishing treatment in favor of palliative, end-of-life support such as hospice care. That open opposition has been replaced in most cases with careful circumspection. Many oncologists recognize a threshold beyond which continued treatment does more harm than good even though they may struggle to unite that recognition with the Hippocratic imperative to heal. This threshold, however, may not always coincide with patient or family preferences.

An oncologist may be asked to taper off or stop treatment at a juncture where the oncologist foresees, with statistical and collegial support, that continued treatment is still likely to benefit the patient. In equally problematic situations the reverse may occur. Crawley and her colleagues cite as an example an African-American man with metastatic colon cancer who angrily rejected his physician's suggestion that they had reached a point where the interventions would be costly and would serve only to prolong the man's suffering (Crawley et al., pp. 673-675). The patient demanded that he receive every medical test and procedure available regardless of the cost. This insistence, the physician felt, was based on the man's inability to grasp the limitations of the technological options still available to him.

The provision of good end-of-life care for cancer patients frequently is complicated by disagreements, poor communication, and cultural differences. However, there are strategies that oncologists can adopt to alleviate end-of-life pain and suffering among their patients. Foremost is a willingness by a physician to probe beneath the surface for explanations of why patients and/or families may or may not desire an option such as hospice care. Investigating the case mentioned above further, Crawley et al. discovered that the physician, a European-American, consulted an African-American colleague for advice. As an ethnic "insider," the colleague was able to point out that African-Americans who have suffered discrimination may fear neglect if they do not insist on maximal care. The colleague also stated that many patients seek aggressive treatment because they value the sanctity of life, not because they misunderstand the limits of the technology available to them, as the patient's doctor had suspected (Crawley et al., p. 675). Enlightened by this and other information, the doctor met again with his patient and reopened the discussion with greater understanding about the patient, his cultural background, and his preferences.

A unique problem in end-of-life care arises when the physician's best-intentioned efforts appear to resemble physician-assisted suicide or euthanasia. The classic case involves the terminally ill patient whose death may be hastened by high doses of morphine. Discerning clinicians and ethicists usually can recognize whether a physician's goal in such cases is to relieve pain or respiratory distress—a fundamental clinical obligation in the eyes of many—or whether the objective is to hasten the patient's death, a goal that remains ethically controversial (Kodish et al., p. 2979).

The growing worldwide hospice movement provides an important avenue for improving end-of-life care for cancer patients. Hospice philosophy calls for providing patients and their families with medical, psychological, and spiritual support as they encounter terminal illness. The primary goal is palliation of symptoms and improvement of the quality of life. Antineoplastic therapy may be a part of hospice care, but cure of cancer is no longer attainable and the focus is on comfort. Although tension between the goals of cancer treatment and the goals of hospice care may arise, they need not be incompatible. Patients who develop a trusting relationship with an oncologist may feel abandoned if their care is transferred abruptly to a hospice team. For this reason oncologists should remain active in the care of patients with terminal cancer, using hospice services as an adjunct rather than a replacement for providing excellent care.

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