Communication in Cancer Care (PDQ®): Supportive care - Health Professional Information [NCI] - Communication Along the Disease Trajectory
Patients consistently noted that they did not like the physician beginning the communication of bad news with words such as "unfortunately."
Whereas most physicians in Western countries tell their patients that they have cancer, information about prognosis is less commonly presented. Most cancer patients report that prognostic information is of great importance to them. If patients are actively encouraged to ask questions, prognosis is the one area in which they desire information and actually increase their question-asking. In one study,[Level of evidence: II] prognostic information that was rated as most important by women with early-stage breast cancer included knowing the probability of cure, disease stage, and chance of curative treatment and receiving 10-year survival figures comparing receipt and nonreceipt of adjuvant therapy. Probability of cure and knowledge of disease stage were also identified as high-priority needs in another study of women with early-stage breast cancer.[Level of evidence: II] However, patients clearly vary in their desire for prognostic information, and patients with more advanced cancer may be less inclined to receive information about their life expectancy; many others may be ambivalent. It has also been shown that physicians and their patients who have advanced cancers often overestimate the probability of survival. Thus, there is considerable controversy about how to discuss prognosis with patients; a number of articles have made valuable suggestions.[24,25,26,27,28]
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]