Palliative care: should oncologists be placed in one category or another?

I received the “Just Published…” email from The Mary Ann Liebert Company yesterday. It highlighted an editorial and a qualitative study on oncologists’ approach to end-of-life care.

Let me first disclose several facts: I am an oncologist, currently at an academic institution taking care of patients with melanoma. I am interested in end-of-life care and I underwent communication skills training with Bob Arnold (one of the authors of the original article) and I consider him a mentor.

The study in the Journal of Palliative Medicine is based on 18 interviews with oncologists at academic centers after the death of one of their patients. Of note, the patients had solid tumor malignancies, hematological malignancies with or without having undergone autologous or allogeneic transplantation (so this was my fellowship).

Yes, there are limitations of the study (academic setting, oncologists’ perspective only, etc) but it makes a few points. There are two types of oncologists ... One focuses on the biomedical aspect of caring and another focuses on biomedical as well as psychosocial aspects of caring for patients. Those oncologists who focused on biomedical and psychosocial aspects of caring were more likely to have a defined approach or method of discussing goals of care (read, end-of-life discussions), while others did not. Those oncologists who did not have a defined approach reported were less likely to make recommendations for end-of-life care compared to their counterparts and were more likely to be frustrated for not being able to influence the outcome. Potentially these frustrations can lead to dissatisfaction with work and burn out.

In his Notes from the Editor, Dr. Charles von Gunten, editor-in-chief of the Journal of Palliative Medicine, raises the issues of how palliative care doctors should deal with oncologists based on the above two classifications. At first reading, I was a bit ticked off for being brushed into one category or another. But then the question rose, how does one decide or judge? Is it based on outcomes? Is it based on approaches? In the past few weeks I have had two patients who died under very different circumstances. Both had metastatic melanoma. One patient died at home, surrounded by his family and was never hospitalized; the other died in the intenstive care unit after sixth admission in six weeks. Why the difference? Same disease, same oncologist (I like to think I am the type that focuses on biomedical as well as psychosocial aspects of care and have a framework for talking to patients about end-of-life care), similar approach ... but very different outcomes. How would I be classified? How should I be judged? Did I fail my patient?

I have also struggled with patients who are undergoing very aggressive care (as some of the patients in this study) such as allogeneic bone marrow transplantation, where the goals have been for “cure” despite possible life-threatening complications (typically quoted as 15% to 20% mortality due to the treatment). How should I approach these patients and situations? If they make it through “this” particular set back, they may be alive and well a few months later, but you just never know!

What do you think, HemOnc Today readers? What are your experiences? Share them with your colleagues.