Digest Commentator(s): Jonathan Avery, Ph.D., Post-Doctoral Research Fellow, Department of Supportive Care, Princess Margaret Cancer Centre (University Health Network, Toronto)
Digest Editor: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto
In caring for patients with advanced cancer, there may come a time when clinicians have to tell their patients that tumor-directed treatments are no longer effective, and the side-effects and complications outweigh the benefits. In such cases, a timely decision to stop this type of treatment is associated with better patient outcomes. However, empirical research has demonstrated a tendency towards more aggressive tumor directed therapy closer to end of life (EOL) particularly in the adolescent and young adult (AYA) population. In the article “Rather one more chemo than one less. . .”: Oncologists and Oncology Nurses’ Reasons for Aggressive Treatment of Young Adults with Advanced Cancer, Laryionava et al. explored the reasons as to why this tendency occurs.
Twenty-nine qualitative face-to-face semi-structured interviews were conducted with oncologists (n= 22) and nurses (n= 7) working at the Department of Hematology & Oncology at the University Hospital of Munich, Germany. The sample consisted of fellows (n= 13; 45%), senior physicians (n= 9; 31%), and nurses (n= 7; 24%), who varied in their working experience from 8 months to 34 years. Their age range was 22–64 years. An interview guide was developed that asked specific questions and probes about oncologists and oncology nurses’ views on treatment decisions with young adult patients with advanced cancer. Interviews were analyzed using the grounded theory approach.
The authors highlight three themes that explain the tendency for more aggressive treatments with AYA closer to EOL: 1) Patient’s preference for further treatment; 2) Oncologists and nurses’ perception of unfairness of dying at a young age; 3) Oncologist’s identification with patients.
Why I liked this article
What is most interesting about this article is how the results illustrate the decision to stop tumor-directed therapy with AYA is complicated and multi-factorial involving the consideration of patient preferences and, what the authors describe as, the “emotional entanglement” of clinicians. This entanglement emerges from the clinicians’ own thoughts and feelings from treating a young adult dying from cancer. Participant quotations highlight that not only does it feel unfair when young adult dies from cancer, there appears to be something inherent with the stage of life of the AYA that “we”, as health professionals, reflect fondly on. Falling in love, having a family, and establishing our lives are significant and meaningful life experiences that we value and cherish. Caring for young adults with advanced cancer and seeing their hopes and dreams ripped away is very difficult to witness because of our own experiences and fondness for that stage of life. This difficulty appears to be impacting the clinical judgement as to whether aggressive tumor-directed treatments close to end of life would be an appropriate or effective mode of therapy for AYA.
As a post-doctoral research fellow developing my own program of research, I find this type social dynamic between clinician and patient very interesting. For better or for worse, the emotional entanglement emerging from this study can at times impact how care is provided. I hope to explore this type of dynamism in my own research particularly in the area of AYA palliative care to ensure that both clinicians’ and patients’ well-being are considered when approaching difficult circumstances such as EOL care.
Laryionava K, Heubner P, Hiddemann W, Winkler E. "Rather one more chemo than one less...":Oncologists and oncology nurses' reasons for aggressive treatment of young adults with advanced cancer. Oncologist. 2018;23(2):256-262.