Communication in Cancer Care (PDQ®): Supportive care - Health Professional Information [NCI] - Communication Along the Disease Trajectory
Transition to Palliation and End-of-life Care
Communicating with dying patients can be complicated by practitioners' own reactions such as anxiety, sadness, and frustration, combined with the historic tendency in Western medicine to focus on cure. The data from one study suggest additional reasons. Physicians strive to achieve a delicate balance between providing honest information and doing so in a sensitive way that does not discourage hope. Physicians may fear that the revelation of a grim prognosis may psychologically damage patients' hopes and may diminish their will to survive through a form of prophecy. This fear is consistent with a Western cultural assumption that one needs hope to battle cancer. Physicians are also uncomfortable with putting odds on longevity, recurrence, and cure because they do not know when or how individual patients will die. In one study,[Level of evidence: II] hope was a constant theme of the respondents. However, many patients do not measure hope solely in terms of cure, but hope may represent achieving goals, having family and oncologist support, and receiving the best treatment available.[30,31]
The value of end-of-life discussions is not solely psychological. In addition, aiding patients with end-of-life discussions through this kind of communication has an impact on health care costs. In a large study of people with advanced cancer, patients who reported having end-of-life discussions with their physicians (n = 188) had significantly lower health care costs than did patients who did not have these discussions (n = 415). This was demonstrated by a reduction in resuscitation, ventilator use, and intensive care stay. There was no difference either in survival time or in the likelihood of receiving chemotherapy for patients who discussed end-of-life preferences with physicians (n = 75) and those who did not (n = 70). Higher costs were associated with worse quality of life at death, as rated by the patient's caregiver (hospice nurse or family member).[Level of evidence: II]
Patients facing death have myriad concerns that include the following:[33,34,35,36]
- Leaving children and other loved ones behind.
- Decline in the socially based aspects of one's identity.
- Being unable to fulfill normal roles.
- Fear of burdening loved ones.
- Loss of control.
- Deterioration in personal appearance.
- Needing help with intimate personal care and routine activities of daily living.
- Worries about mental awareness.
- Pain and management of symptoms.
- Quality of life.
- Achieving a sense of completion.
- Having a good death.