Oncologists Missing Opportunities to Have End-of-Life Discussions, Study Finds

Physicians may be uncomfortable discussing end-of-life issues and avoid having the conversations.

In the outpatient setting, a significant number of oncologists miss opportunities to have end-of-life (EOL) discussions with their patients, a recent research article found.

EOL treatment that does not align with patient goals is a major public health problem that can have a negative impact on patients and families. For oncology patients, EOL treatment that does not align with patient goals includes chemotherapy during the last 14 days of life, ICU care during the last 30 days of life, and late referral to hospice.

The recent research article, which was published by JAMA Network Open, is based on an analysis of more than 400 outpatient encounters at two academic medical centers. The patients had stage IV malignant neoplasm and were expected to be admitted to an ICU or to die within one year.

The study features two key data points.

• In 423 outpatient encounters, only 21 (5%) included EOL discussions
   
• In a random sample of 93 of the outpatient encounters, 35 (38%) included missed opportunities for EOL discussions

"Opportunities for EOL discussions were rarely realized, and missed opportunities for these discussions were common, a trend that seemed to mirror oncologists' treatment style," the research article's co-authors wrote.

There were three kinds of missed opportunities to hold EOL discussions, according to the research article.

1. An inadequate response to patient concerns about disease progression: "When patients or caregivers expressed concern over disease progression or dying, they were often met with partial, avoidant, or absent responses from their oncologists. When oncologists did respond, they often deflected concerns, rather than using them as openings to explore patients' goals, values, or preferences for care, according to best practice in patient-practitioner communication," the research article's co-authors wrote.

2. Engaging in optimistic future talk: "Optimistic future talk describes oncologists' responses to patients' concerns regarding disease progression or dying. Instead of addressing patients' concerns directly, oncologists often shared anecdotes of patients who exceeded average life expectancy," the co-authors wrote.

3. Concern of discontinuation of treatment: "Oncologists frequently expressed concern over treatment discontinuation, often referred to as a holiday or break. … Often, oncologists folded statements of concern about discontinuation into discussions of future treatment, leaving no room to discuss discontinuation," the co-authors wrote.

The co-authors speculated about the reasons why oncologists avoid EOL discussions. "Evidence suggests that physicians may be uncomfortable discussing EOL topics and, thus, avoid them. In addition, emotional distancing due to physician stress or burnout may decrease the likelihood that physicians pick up subtle cues from patients regarding concerns about their disease," they wrote.

"It is also possible some oncologists believed they were sparing patients from conversations they were not yet ready to have, or preserving hope—albeit, potentially to the patient's detriment—of continuing treatment. In this vein, some oncologists may have felt a sense of denial as to their patients' disease progression, particularly after developing close relationships with their patients," they wrote.

Despite decades of effort to improve oncologists' EOL discussions, more work is needed, the co-authors wrote. "Future efforts must address barriers, such as oncologists' fear of upsetting patients and discomfort engaging in EOL discussions, and challenges inherent to providing a time-sensitive prognosis, in tandem with the need to respond to patient emotions and express empathy."

Related: Patients' End-of-Life Surrogates Aren't as Ready as They Think