Real Talk for Oncologists

Cancer physicians discuss the challenges of end of life discussions

(RxWiki News) What if you had to tell someone that they were going to die? How would you do it — by preserving hope, but preparing this individual for the final transition?

While these conversations aren’t uncommon for oncologists, that doesn’t make delivering this sort of news any easier for them.

A recent study looked at the challenges oncologists face when having these talks about death with patients. These cancer doctors said talking about dying was the most difficult and stressful part of their jobs.

"Be honest in conversations with your oncologist."

Leeat Granek, PhD, a professor at Ben-Gurion University of the Negev (BGU) in Beer-Sheva, Israel, led the study in which 20 oncologists were interviewed about talking with patients about death.

The oncologists in the study defined effective communication as being open and honest with patients and have ongoing conversations about the goals and results of treatment.

The most challenging part of these conversations, they said, was balancing hope and being realistic about the end of life nearing.

"What makes our study unique is the opportunity to get into the oncologists' heads, to understand what they perceive to be the goals of effective communication about the end of life, as well as what makes it difficult for them to achieve these goals," Dr. Granek said in a press release.

"Through the analysis, it became apparent that there is tension between what are perceived to be good communication strategies and the significant number of barriers to implementing them," said Dr. Granek.

This study revealed that there were three areas that made these conversations particularly difficult. These difficulties were related to physician, patient and institutional factors.

Physician factors included personal discomfort the doctors felt about the topic of death, as well as difficulty telling a patient that treatment hadn’t worked and that palliative (comfort) care had become the best option.

Another barrier, which the authors called the “death-defying” mode, had to do with physicians denying the inevitability of death so that treatment continued.

Patients can also block open conversations about dying because they or their families don’t want to talk about it, according to the oncologists in the study.

Institutional factors that made it difficult to talk about death included a lack of procedures relating to end-of-life discussions and lack of training for physicians about how to have these conversations.

"Oncologists have to deal with very serious things with their patients and often with patients they do not have a long standing relationship with. So, they might be breaking bad news to a new patient that was sent to them by another doctor," said Christina Puchalski, MD, MS, FACP, founder and director of the George Washington Institute for Spirituality and Health (GWish).

She described a typical scenario: “Because physicians are not completely prepared for these complex conversations, they rest on what is ‘comfortable’ for them and what they feel safe in — i.e., only the physical aspects of care."

"This then becomes frustrating for patients because, as numerous studies have shown, patients want more 'humanistic' physicians — who are not just scientifically excellent but whole person oriented, willing to be vulnerable with their patients,” Dr. Puchalski said.

One of the missions of Dr. Puchalski’s work at GWish is to help physicians become more humanistic.

"We teach the communication skills — how to break bad news, how to talk about dying and living while dying, how to address spirituality, how to walk the line between realistic prognosis without taking hope away," she said.

The study authors concluded that more research is needed in this area. "Given the ubiquity of death in oncology, open discussions and appropriate training and support for oncologists in this realm are essential.

While there is heterogeneity among oncologists in their comfort with discussing end-of-life issues, a multipronged approach that involves support for the physicians, patient education, and institutional supports and allows for some customization is necessary," they wrote.

This study was published in a recent edition of Journal of Oncology Practice.

The research was supported by the Juravinski Cancer Centre Foundation, Hamilton, Ontario, Canada. No conflicts of interest were disclosed.

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Review Date: 
June 9, 2013