Cancer Care: A Microcosm of the Problems Facing All of Health Care

When is enough treatment really enough? This question often follows physicians in all areas of medicine and their patients throughout the course of treatment. The dilemma can be particularly difficult for oncologists for whom, giving an accurate prognosis is difficult. They tend to feel optimistic about a patient's chances of benefiting from treatment and ambivalent about dashing the hopes of patients by giving them pessimistic feedback. As a result, oncologists usually prefer to talk about the goals of care with patients rather than about whether or how likely they are to die of their disease, about how long they have to live, or the anticipated benefit from chemotherapy compared with palliative care.

Patients, too, often struggle to feel satisfied when making treatment choices. Some either don't want to know their prognosis or expect to beat the odds. Many patients with cancer want aggressive treatment until the very end, no matter how small the benefit or how great the toxicity. Adverse effects are less of a concern for patients than for their health care providers (1).

This fraught patient–physician dynamic can result in a “cascade of aggressive care,” according to Neil S. Wenger, MD, MPH, a professor in the University of California, Los Angeles, department of medicine and director of the UCLA Health System Ethics Center. The cascade starts when the physician does not discuss a realistic prognosis with the patient or does not anticipate the trajectory of the patient's decline. Then, when the patient's clinical deterioration merits intensive care and organ failure necessitates more machines, the result may be aggressive, ineffective care that promotes physical, psychological, and spiritual suffering. The morale of the patient and the family goes down while costs go up.

For instance, it is not uncommon for chemotherapy to be given near death. A study published …