Specific training for young oncologists, particularly in managing patient expectations regarding end-of-life treatment, is paramount in providing effective, patient-centred end-of-life care
End-of-life care, in the last months or weeks of a patient’s life, is a very personal choice that relies on detailed discussions and shared decision making between the patients, their families and healthcare providers. It is part of the physician’s responsibility to ensure that the patient understands the implications of the care at this point of the disease and that he is aware of the management options available.
Often, active anticancer therapy is discouraged at the end of life due to an imbalance between low expected benefits and potential toxicity. The ESMO Guidelines recommend that chemotherapy and immunotherapy should not be used in the last weeks of life and radiotherapy should not be used in the last days of life (ESMO Open. 2021;6:100225). Inappropriate use of treatments has been identified previously (J Palliat Care. 2021;36:73–77). Now, a study presented at the ESMO Congress 2023 (Madrid, 20–24 October) including 616 patients with advanced cancer with life expectancy of ≤12 months reported that 28.7% of patients received anticancer therapy in the last 3 months and 12.1% received it in the last month of life. This occurred despite the incorporation of a complex intervention strategy designed to reduce anticancer therapy use in the last 3 months of life compared with conventional care (Abstract 1592MO). The strategy consisted of a physician educational programme, compulsory palliative care referrals at inclusion and patient symptom reporting prior to all consultations. There was no difference between the groups in the median time between anticancer therapy and death or in quality of life.
In clinical practice, while excessive, unnecessary intervention should be avoided, active therapy at end of life can be an option in some cases, if both physician and patient agree on its use. A key element, in fact, is understanding and managing expectations. Good communication is required to ensure that the aims of treatment, as understood by the patient, their caregiver and the physician, are aligned (J Clin Oncol. 2020;38:2366–2368). It should be made clear that for most patients at the end of life, efficacy of anticancer therapy is more of an exception than a rule. This may involve difficult conversations, but the alternative – that is, leading the patient to believe that treatment is more than palliative – is misleading. Quality of life should also be highlighted. Adverse events from systemic and radiotherapy can be severe for patients at any stage.
Delivering end-of-life care poses specific challenges for young oncologists. We have all been trained during our residency in the best ways to deliver bad news and to communicate with patients at the end of life. However, our enthusiasm to achieve good outcomes for all patients may lead young specialists to try every available treatment at all stages of disease. It is particularly difficult when these are patients we have followed from their initial, early-stage diagnosis, whose remissions and subsequent relapses we have witnessed and who have become close to us, implicating an emotional component to treatment decisions.
Closeness with the patient is something that might distinguish young oncologists from more senior specialists, whose experience has helped them to more effectively compartmentalise feelings. Young oncologists are at higher risk of becoming too involved in patients’ lives and so when therapy we have delivered fails, it can hit us hard and we can often blame ourselves. Comprehensive training for young oncologists on how to prepare us and patients for end-of-life care should be a part of education for every oncology specialty. Guidance should include the recognition and understanding of changes in mood and behaviours that we sometimes see in the palliative setting in patients who may have trouble accepting the situation and who can become more emotional and volatile. Another key message that needs to be emphasized is mention of the provision of palliative or supportive care early within the treatment plan, so that the fact that no active interventions can be medically justified at a certain time of their treatment is not a complete surprise to a patient.
Psycho-oncologists also offer important expertise and can be called on to give input to particularly difficult cases, offering support not only to patients and their families but also to their medical caregivers.