Other Voices: Chemo at the end of life
As the executive director of Hospice of the Foothills, I am constantly looking for interesting articles that shed light on the subject of end-of-life care.
Recently, I came across an article in the California Hospice & Palliative Care Association newsletter that referenced a June 11 Journal of American Medial Association (JAMA) article entitled, “The role of chemotherapy at the end of life.”
Given the future outlook of health care in our country, and the aging of our population, this article is extremely important and timely, so I am relaying it to our community for the benefit of all who have any interest in learning more about the subject of how chemotherapy relates to end-of-life care.
The article begins: “Patients face difficult decisions about chemotherapy near the end of life. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice.
“Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation.”
The authors say it is important to identify the goals of chemotherapy and to know who is likely to benefit from chemotherapy in the late stages of a disease. “Patients are unlikely to benefit from chemotherapy when they have already been failed by the standard regimens, have poor performance status and otherwise have a poor prognosis.”
The authors note that there are other reasons for not choosing chemo at the end of life. Among them are the negative side effects, the fact that it may prevent patients from entering hospice, the costs and lost opportunities for preparing for a peaceful death.
The article suggests that physicians need more honest communication with patients. Other suggestions include bringing up hospice soon enough for it to be part of the standard cancer care, not just a few days before death.
A sidebar to the article contains a list of questions that patients need to ask about palliative chemotherapy. Questions to ask about treatment include: “What is my chance of cure? What is the chance that this chemotherapy will make my cancer shrink? Stay stable? Grow? If I cannot be cured, will I live longer with chemotherapy? How much longer?
“What are the main side effects of the chemotherapy? Will I feel better or worse? Are there other options, such as hospice or palliative care? How do other people make these decisions? Are there clinical trials available? What are the benefits? Am I eligible? What is needed to enroll?”
The questions suggested for prognosis are: “What are the likely things that will happen to me? How long will I live? (Ask for a range, and the most likely scenario for the period ahead and when death might be expected.) Are there other things I should be doing? Will? Advance directive? Durable power of attorney for financial affairs? Trust?”
On family issues, patients should ask if the physician will help them talk to their children. They should ask who is available to help cope with spiritual and psychological issues. And, lastly, they should ask, “What do I want to pass on to my family to tell them about my life?”
In conclusion, the authors say: “The conundrum for today’s oncologist is that moving on to third- or fourth-line chemotherapy may be easier than discussing hospice care, the patient and family may be less upset, and they may prefer to not discuss the issue with the oncologist.
“Adverse effects of chemotherapy may be minimal, discussions take more time, and chemotherapy intervention is better compensated than are discussions. However, without a clear goals-of-care discussion, patients … and families may be unprepared for what the final few months, weeks, or even days may bring.
Through honest and respectful communication about the last stages of cancer, physicians can give patients a genuine choice about how to spend their last phase of life.”
Dennis Fournier is executive director of Hospice of the Foothills.
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