‘Global problem’: Numerous factors, biases contribute to overtreatment at end of life
Key takeaways:
- Optimism bias and fear of having talks about palliative care contribute to overtreatment of people with cancer at end of life.
- Clinicians should be aware of their own biases regarding end-of-life care.
Nathan I. Cherny, MD, has worked all around the world.
At every stop — from Australia to Israel, and Memorial Sloan Kettering Cancer Center in between — he has seen people with cancer receive overly aggressive treatment at the end of life.
“It’s clear that the treatments are more likely to cause harm than good,” Cherny, director of the multidisciplinary cancer pain and palliative medicine service at Shaare Zedek Medical Center in Jerusalem, as well as associate professor in medicine at Ben-Gurion University of the Negev in Israel, told Healio.
“I see nurses who are in a situation of moral distress, having to administer treatments that they feel are not in the patient’s best interest,” he added. “I see patients in my palliative capacity who say to me, ‘Why didn’t the doctor tell me that the chances of this helping are so small, or that I could suffer such terrible side effects? Had I had that information, I never would have chosen to go this path.’ This is not a local problem. The international data shows that this is a global problem.”
In a review published in ESMO Open, Cherny and a cohort of multinational colleagues highlighted numerous reasons why overtreatment occurs among patients approaching the end of life, including optimism bias, the “counterphobic determination to treat” and hope preservation.
“I don’t see this as something that will cause a revolution in care, but I hope it will contribute to an evolution of care such that our profession becomes more careful and circumspect regarding this issue,” Cherny said. “I hope it becomes the norm — rather than the exception — that oncologists are well versed and well equipped to deal with this transitional phase of care.”
Background
Between 10% and 40% of individuals with cancer receive treatment within the final few weeks of their life, according to study background.
Healio previously reported that patients with various advanced or metastatic cancers who received therapy at institutions that administered the most end-of-life anticancer therapies did not derive discernable survival benefits compared with those cared for at centers that administered the fewest end-of-life treatments.
ASCO and the National Quality Forum (NQF) previously endorsed NQF 0210, which measures the number of patients who died of cancer after receiving chemotherapy in the last 14 days of their lives. However, the percentage individuals nationwide who received anticancer treatment in their final 2 weeks of life did not change from 2015 to 2019 (mean, 17% in both years).
Previous studies have showed extra treatment at end of life increases the likelihood of emergency room visits, admission to hospitals and intensive care units, and reduced quality of life, Cherny said.
“There have been multiple attempts to try to address it — none particularly successfully,” he added. “Part of the issue is that there’s been a failure to appreciate the complexity of multiple factors that contribute to the problem.”
Explanations for overtreatment
The rationale for overtreatment differs based on who is asked.
“If you ask the doctors, they say that they’re being pressured by the patients and the patients’ families,” Cherny said. “If you ask the nursing staff and the doctors’ colleagues, you’ll hear that the doctors are overly optimistic about their treatments, and that it’s much easier for them to offer another line of therapy than it is to engage the patient and the family in a discussion about end-of-life care.”
In their review, Cherny and colleagues outlined multiple factors for both clinicians and patients that contribute to overtreatment, including psychological, social, cultural and cognitive biases.
They listed more than 20 contributing factors, including desire for control of the cancer, denial and anger, family pressure and hope preservation.
The two factors that contribute most to overtreatment are optimism bias and the “counterphobic determination to treat,” which involves clinicians having a difficult time introducing the suggestion of palliative care revert to offering further treatments, Cherny said.
“In response to this fear, they just responded with pushing on with another treatment,” Cherny added. “These were much easier conversations to have than a conversation about the potential need for end-of-life care and a change in the course of the therapeutic strategy.”
“We are much more optimistic about last-ditch treatments for patients with resistant disease than is justified,” Cherny said. “There’s often a suspension of critical thinking and critical reading of data.
‘Reframing hope’
Studies have asked patients how much time they would want added to their life if they were to go forward with another treatment. Their answers ranged from 18 months to 2 years, and it is “extraordinarily rare” for late-line treatments to achieve that, Cherny said.
“In this era of so many new agents that have become available, there’s almost a cavalier approach of, ‘Why not try this? We don’t have much to lose,’” Cherny said. “The truth is that patients do have a lot to lose because, even with these new treatments — such as immunotherapies — a nontrivial proportion of patients suffer complications, which are sometimes severe and life-threatening. When this is off-label, patients will often have to pay for these things out of pocket with very substantial financial toxicity. There’s also the time toxicity of time spent in a hospital and around ineffectual treatments, which could otherwise have been devoted to important family relationships.”
Focus on palliative care begins with “reframing hope,” Cherny said.
“Hope is a really critical issue in people’s lives,” Cherny said. “It’s one of the things that maintains their motivation to live and, when all hopes are pinned on either curing the disease or controlling the disease, people lose sight of the fact that there are other meaningful and important hopes, such as maintaining important relationships, leaving a legacy, finishing one’s life in comfort and surrounded by people that you love, tying up unfinished business. [Clinicians can] help patients transition and reframe their hope and refocus their hope, the hopes that are important and which are achievable in this time.”
Cherny and colleagues detailed a 12-point approach to having end-of-life conversations with patients. That approach highlights acceptance of the difficulty of the talk, honesty and transparency, importance of quality of life, realistic goals, informed decision making, counseling, and more.
“When I talk to patients, I tell them that not only is there courage in taking another line of treatment. but there’s also courage in saying, ‘I recognize that this is more likely to harm than to help me, and it’s time to stop,’” Cherny said.
When Cherny has patients who are near the end of life, he often tells them further treatment likely would cause more harm than good, saying something like: ‘I can’t in good conscience recommend a further line of treatment. I appreciate that this is very difficult for you to hear. You want the best of care, and you need peace of mind that you are getting it, and if you’d like to get another opinion about that, that’s totally fine by me. However, out of care for you, I need to be honest and candid about what treatments can and cannot do.”
Some patients will still want treatment and, in those instances, setting boundaries is critical.
“If we’re going to do this, it needs to be on shared terms,” Cherny will tell patients. “Those terms are that if we see this treatment is harming you, or if we see this treatment is not working, we stop.”
Responsibility for decisions does not need to fall solely on oncologists, Cherny added. Palliative care physicians, social workers, chaplains and others can be part of a team to assist patients with their choices.
‘It’s a different treatment’
The number of patients who are overtreated differs at each institution.
“Each institution has its own culture of care,” Cherny said. “When your mentors display very aggressive approaches to treatment, even for patients with far advanced cancer, that becomes part of your informal education. People learn this, and this is one of the ways in which people adopt biases through the unspoken curriculum learned through role modeling. Where you have departments where there’s a strong culture of questioning and of looking at the risk-benefit ratio, that affects clinicians in a different and a more positive way.”
He said each institution could conduct an audit of itself to determine how much overtreatment occurs. How many patients die within 2 to 4 weeks of treatment? Does this happen with multiple physicians, or just a few?
“Often we remember our best-performing patients, and we forget our worst-performing patients,” Cherny said. “This is a recall bias, and it’s only once that you’re aware that there’s a problem that people will be prepared to start to act.”
Future research could investigate how often clinicians and patients express various biases — such as optimism bias — in decision making at the end of life.
More training also is needed for clinicians regarding to communication skill to transition patients to palliative care, Cherny said.
His hope with the review paper is to make clinicians more aware of the problem and self-aware of their own biases.
“It’s never about not treating [patients] anymore,” Cherny said. “It’s about what is the appropriate treatment to continue with. This is why we’ve been emphasizing for a long time the importance of integrating oncology and palliative medicine units and starting palliative care at an earlier part of the disease trajectory, particularly for patients with metastatic disease so there can be a seamless and smooth transition from a focus on antitumor treatments to increasing focus on the palliative care needs. It should never be where patients feel suddenly abandoned. It’s a different treatment that’s needed now, and a different emphasis on treatment.”
For more information:
Nathan I. Cherny, MD, can be reached at nathan@cherny.org.
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