Recently, researchers examined whether there had been any changes in the way terminal cancer patients died from 2014 to 2019, given the increased information available on hospice, palliative care, and advanced end-of-life planning (EOLP). They asked whether those who were terminal continued aggressive treatment until their demise. The authors anticipated a decrease in this, but found that the frequency of cancer patients who continued aggressive therapy had not declined. The study did not examine decision-making. Still, the researchers, based on other studies, theorized that the lack of change resulted from a confluence of physician and patient factors.

The physician component consisted of their management philosophy, which was shaped by their training, the treatment beliefs under which they were trained, and their clinical experiences. These factors influenced the information they provided, as they might predict a more optimistic prognosis than justified, avoid discussing EOLP, support (over)intensive treatment, and/or overemphasize treatment effectiveness while minimizing its side effects. Oftentimes, given their statements, physicians will offer treatments they know to be of little value, believing that patients expect them to propose something rather than admit there was nothing realistic left to offer.

It is even possible that an older oncologist may have limited awareness of current hospice or palliative care, or may not accept the American Society of Clinical Oncology recommendations that these issues should be discussed close to the time a patient is provided a diagnosis and that aggressive treatments should be discontinued when they prove to be ineffective.

Preferably, a knowledgeable but neutral individual should discuss a patient’s disease, prognosis, treatments, alternatives, and other relevant information with him/her and provide the patient with simplified reference material. This information provision will require more than a single session, as receiving a cancer diagnosis can be disquieting, and a patient will need time to come to terms with it, and providing too much additional information at the same session will likely be unheard.

Waiting a few days before another meeting is not life-threatening. By this time, the patient will have questions to ask, leading to issues that require discussion, and s/he will (hopefully) be more receptive. Patients have a large amount of information to absorb and several decisions to make, and it is unrealistic to expect them to do so in a single session. The sessions and necessary decisions should be completed within a short period; however, as prolonged decision-making can result in delayed care and a subsequent impact on the length and quality of life.

Information, besides treatment options and prognosis, should include research studies on their cancer that they may be eligible for, or how to search for them. This is information that is too often neglected, EOLP, the benefits of end-of-life psychotherapy, the possible advantages of Marijuana and/or Psilocybin, terminal sedation, and “medical aid in dying” options where they are legal, and support groups for themselves and family members.

An additional topic is the value of palliative care to minimize the side effects of treatments. This is a standard of care, but not all oncology facilities or physicians offer this option. Patients should inquire about its availability and consider seeking a physician or facility that provides it if their initial choice does not provide it.

Patients should be encouraged to delay a decision on advertised medications until they have sufficiently considered their potential benefits and shortcomings, as they tend to be more hype than reality. Considerations regarding hospice and other terminal arrangements should not be postponed until therapy has been exhausted. The average hospice stay is three days, which is too brief for a patient or their family to fully benefit from its services. With patient permission, his/her designated representative should also attend these sessions.

Patient issues may prevent considering all options. One is overoptimism, that with treatment, the neoplasm will not only remit, but will be cured. Too frequently, people conflate “remission” with “cure,” and cannot be disabused of this belief. Physicians sometimes encourage this overoptimism, for example, by stating that “mortality tables do not represent individuals” to allay patient anxiety. Stating that tables are reasonably predictive, but individual variables (e.g., response to medication) can influence one’s progress, is more accurate. Also, a reasonable level of anxiety can be motivating for a patient.

The longevity misbelief is further fueled by medication advertisements promising a longer, high-quality life but downplaying severe side effects that have a reasonable probability of causing secondary illnesses, functional limitations, ED visits, hospitalizations, and an increased likelihood of an in-hospital death, despite most patients’ preference to die at home. Further, they fail to mention that this death could occur sooner than may have resulted from the cancer. The ads also do not mention that when the cancer returns, treatment can be more challenging or ineffective.

Additionally, many older people grew up with the “war on cancer” campaign, that cancer had to be battled, even until one’s dying breath, and that EOLP and hospice connoted surrender. Medicare reinforces this by requiring patients to stop treatment for it to pay for hospice services, although hospice philosophy does not require treatment abdication.

However, presently, unless one’s religion requires redemptive suffering (e.g., Catholicism), there is no need for anyone to die in extreme pain or in a hospital, unless it is by choice or necessity.

M. Bennet Broner is a medical ethicist.