Informed consent and palliative chemotherapyBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a868 (Published 31 July 2008) Cite this as: BMJ 2008;337:a868
- 1Myton Hamlet Hospice, Warwick CV34 6PX
- 2Mount Vernon Cancer Centre, Mount Vernon Hospital, Middlesex. HA6 2RN
Informed consent is central to management decisions in modern medical practice. However, sharing information with patients about the value of chemotherapy for advanced metastatic cancer is highly challenging. In the linked study (doi: 10.1136/bmj.a752), Audrey and colleagues assess how much oncologists tell patients about the survival benefit of palliative chemotherapy during the first consultation after a diagnosis of metastatic colorectal cancer, pancreatic cancer, or non-small cell lung cancer.1
Although chemotherapeutic options have improved, life expectancy in people with metastatic cancer is often short, survival benefits of treatment may be modest, and the potential for unpleasant or life threatening side effects is high. Nevertheless, chemotherapy is increasingly given closer to the end of life,2 and patients are having to decide whether or not to have treatment at the same time as facing the harsh realities of dying.
To make informed choices, patients need up to date consistent information and comprehensive and expert communication from their oncologists and supportive care teams. However, the literature highlights a lack of shared understanding between patients and their doctors, and between different specialists around key areas—the prognosis of advanced cancer, the aims of treatment, and the chances of benefit.3 Patients’ expectations are also shaped by the lay press and the internet, including information about new treatments that are unavailable through the public sector but can be obtained privately.
Studies from several countries conducted over the past 20 years suggest that patients with metastatic cancer accept lower chances of benefit and higher risks of severe side effects than would be accepted by matched healthy controls or healthcare professionals.3 Wide variations exist, however, with some people accepting treatment with a one week survival benefit and high levels of toxicity and others refusing treatment with a potential two year extension of life and minimal side effects.4
It is not clear why patients accept such high risks for low benefits. Patients’ expectations of prognosis seem to be an important factor; one study reported that people who thought they would to live at least six months if the current plan of care remained the same were 2.6 times more likely to favour life extending treatment over treatment aimed at palliation than those who thought they had only a 10% chance of surviving that long.5 Doctors are generally poor at predicting prognosis, however, tending towards overoptimism,6 and this could have an important effect on patients’ decisions to accept chemotherapy.
Several studies have highlighted the link between the desire to maintain hope and the use of chemotherapy in advanced disease. In one study, maintaining hope was one of the most important aims of second line chemotherapy for breast cancer,7 and another commented that patients may be given chemotherapy because of the need to do something active even if they were unlikely to benefit.8 Patients may also be offered and accept palliative chemotherapy because of a reluctance to confront the issues that surround dying.8
How information on prognosis and chemotherapy is shared probably influences patients’ decisions. One randomised control trial has shown that in patients with breast cancer who were considering adjuvant chemotherapy, those given detailed information about prognosis and treatment drawn from a web based tool made different decisions from those not given such information.9 However, it is difficult to obtain reliable information about prognosis and treatment options in advanced disease, and no nationally agreed information about prognosis or risks of palliative chemotherapy is available. Most patients say they want full information about diagnosis and prognosis3 but do not always receive such information from their oncologist. But they may not necessarily want the whole truth all of the time10 or want to be fully involved in decision making once information has been received.11
In all consultations assessed by Audrey and colleagues, the patient was told that the cancer was incurable and the aim of treatment was to slow tumour growth and provide palliation.1 The details of potential survival benefit were mostly vague or even avoided after an explicit request. No oncologist had a consistent approach to sharing this information and no patterns of information sharing could be identified in terms of disease type or characteristics of the oncologist or service. Although members of the patient’s family were often included in the consultation, other contextual factors were unclear, such as whether the patient had met the oncologist before and whether further support, such as from a specialist nurse, was available. It was also unclear whether patients were offered alternative management, such as supportive and palliative care, or how the patient’s understanding was ascertained.
The authors conclude that more training should be offered to oncologists to help them share such information sensitively and effectively. The study also highlights the need for more research into how to transfer this information more effectively. This should include in-depth exploration of consultations, using techniques such as discourse analysis, to investigate the dynamics of the consultation12; the development and evaluation of nationally agreed and updated information about the prognosis of advanced and metastatic cancer and the benefits of palliative chemotherapy; and the development of decision aids to help patients interpret the information offered.11
Cite this as: BMJ 2008;337:a868
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.