Framework for timing of the discussion about forgoing cancer-specific treatment based on a qualitative study with oncologists

Background Many patients with advanced cancer receive aggressive chemotherapy close to death and are referred too late to palliative or hospice care. Aim The aim of this study was to investigate oncologists’ and oncology nurses’ perceptions of the optimal timing for discussions about forgoing cancer-specific therapy at the End-of-Life (EOL) and the reasons that might hinder them. Design Qualitative in-depth interviews with oncologists and oncology nurses were carried out. The empirical data were evaluated from a normative perspective. Setting/participants Twenty-nine physicians and nurses working at the Department of Hematology and Oncology of a German university hospital were interviewed. Results Health-care professionals differed considerably in their understanding of when to initiate discussions about forgoing cancer-specific therapy at the EOL. However, their views could be consolidated into three approaches: (1) preparing patients gradually throughout the course of disease (anticipatory approach) which is best suited to empower patient self-determination in decision-making, (2) waiting until the patient him/herself starts the discussion about forgoing cancer-specific treatment, and (3) waiting until all tumor-specific therapeutic options are exhausted. Conclusion The empirically informed ethical analysis clearly favors an approach that prepares patients for forgoing cancer-specific therapy throughout the course of disease. Since the last two approaches often preclude advance care planning, these approaches may be less ethically acceptable. The proposed framework could serve as a starting point for the development of concrete recommendations on the optimal timing for EOL discussions.