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

Abstract

Background. Sympathetic and frank communication about the terminalnature of advanced cancer is important to improve patients' prognosticunderstanding and, thereby, to allow for adjustment of treatmentintensity to realistic goals; however, decisions against aggressivetreatments are often made only when death is imminent. This qualitativestudy explores the factors that hinder such communication andreconstructs how physicians and nurses in oncology perceive their rolesin 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 ofHematology/Oncology at the university hospital in Munich, Germany. Thedata were analyzed using grounded theory methodology and discussed froma medical ethics perspective.Results. Oncologists reported patients with unrealistic expectations tobe a challenge for EOL communication that is especially prominent incomprehensive cancer centers. Oncologists responded to this challengequite differently by either proactively trying to facilitate advancedcare planning or passively leaving the initiative to address preferencesfor care at the EOL to the patient. A major impediment to the proactiveapproach was uncertainty about the right timing for EOL discussions andabout the balancing the medical evidence against the physician's ownsubjective emotional involvement and the patient's wishes.Conclusion. These findings provide explanations of why EOL communicationis often started rather late with cancer patients. For ethical reasons,a proactive stance should be promoted, and oncologists should take onthe task of preparing patients for their last phase of life. To do this,more concrete guidance on when to initiate EOL communication isnecessary to improve the quality of decision making for advanced cancerpatients.