With the death this week of Yale surgeon and award-winning author Dr. Sherwin Nuland, the New York Times obituary attributed his 1993 best-selling book “How We Die” as the catalyst that spurred conversations about end-of-life care.
Yet 20 years later, many doctors still have a hard time initiating such conversations with their patients—especially those dying before their time from, say, metastatic cancer. Proof of this comes from a troubling new Dana-Farber Cancer Institute study, which found that more than half of end-stage cancer patients receive chemotherapy during the last few months of their life, and those who received such treatment were more likely to die in a hospital intensive care unit, hooked to a ventilator, rather than at home as they would have preferred.
These patients were also less likely to have discussed their end of life wishes with their oncologist compared to other end-stage cancer patients who opted not to continue chemotherapy, according to the study of terminally ill cancer patients published this week in the British Medical Journal.
“There’s a subtle dance that happens between oncologist and patient,” said study leader Dr. Alexi Wright, an assistant professor of medicine at Dana-Farber, “where doctors don’t want to broach the subject of dying, especially in younger patients, because it makes those patients think we’re giving up on them.”
She and her colleagues followed 386 terminally ill cancer patients and found that the 56 percent who took chemotherapy drugs to relieve pain and keep their tumors in check tended to be younger, better educated, richer, and more optimistic about their prognosis. They were also less likely than those who opted not to continue chemo to have instructions detailing what lifesaving measures should and should not be taken when their death was imminent.
The study volunteers died an average of four months after entering the study, and those who took cancer drugs during the study didn’t live any longer than those who didn’t.
They did, however, receive more painful and costly medical interventions, which led to a worse death: 65 percent died in their preferred place compared to 80 percent of those who stopped treatments. Those taking chemotherapy were more likely to die in a hospital intensive care unit than at home and were more likely to get resuscitated and placed on a ventilator. Not surprisingly, most were referred to hospice very late in the game, within a week before they died.
“Doctors are human beings,” Wright said, “and sometimes we fail to have the clarity to determine when our patients are dying. And even when we do, we may not want to give up on treatments as this study suggests is the case.”
She’s hoping that the findings will raise awareness to help doctors understand that administering chemotherapy to terminally ill patients doesn’t just give them a false sense of hope but also raises the likelihood of denying them a more peaceful death. Nuland died at age 83 of prostate cancer—at his home in Hamden, Conn.