In a survey on the attitudes and practices of nearly 900 oncologists towards palliative care for dying patients and patients with advanced cancer, almost all (92%) agreed that they should receive end-of-life support as well as anti-tumour therapy. Less than half, however, routinely co-ordinate the care of cancer patients at all stages of their disease or collaborate with support teams and social workers. The results of the survey with data from 64 countries (including USA, Australia, Africa, and Asia) was conducted by the European Society for Medical Oncology and were presented today (20 October 2002) at its Congress in Nice.
"There is a big gulf between what people say and what they do," said Dr Nathan Cherny from Shaare Zedek Medical Centre in Jerusalem, Israel, who co-ordinated the survey. "Although there is general recognition that palliative care is important, many oncologists do not see this as an integral part of their role." ESMO also wanted to find out what the barriers might be to becoming involved with their patients' psychological and social issues.
Patients nearing the end of their life due to cancer require extra care for problems such as pain and digestive disorders, anxiety and depression, and complications following chemotherapy. The family members should also be involved with their care and it may be appropriate for the patient to be admitted to a hospice.
There was, however, a significant minority (15%) of medical oncologists who have negative views of the value of palliative care, partly because they did not believe they were sufficiently trained or skilled in dealing with dying patients. They did not consider it to be part of their role and this view was more prevalent in comprehensive cancer centres than at teaching hospitals or private practice.
Just over one-third of the respondents reported that they feel emotionally "burned-out" by having to deal with too many deaths, but the analysis revealed that burn-out was not so much associated with over-exposure to dying people but had more to do with a negative attitude towards the value of palliative care. By contrast, those with a positive attitude had a great deal more personal involvement with these patients, yet appeared to be much less likely to feel drained by their experience.
It has been reported in the past that burn-out by medical oncologists is associated with depression and impacts adversely on patient care. They are more likely to endorse euthanasia or assisted suicide. "Physicians who have had bad experiences administering end-of-life care should be given advice and psychological support to help them communicate more effectively with severely ill patients," said Dr Cherny.
ESMO has recognised the need for improvement in the quality of supportive and palliative care delivered by oncologists around the world. To this end, it has produced a policy reflecting its commitment to continuity of care and defining standards of excellence in this area. As well as addressing the role of the oncologist in the provision of this type of care and the need for adequate training, the policy also outlines ethical issues related to disclosure of information, consent, and decision making. Minimal standards for the provision of care by cancer centres include:
- Routine assessment, control and evaluation of physical and psychological symptoms
- Emergency care
- Ongoing supportive programmes, social work and psychological care
Dr Cherny called on oncologists to audit the care of patients with advanced cancer. "Assess their pain, keep in contact with social and home service providers and work out what you need to be skilled in, to ease your patients' suffering," he said.
Caring for a patient with cancer requires more than just treating the tumour. "Doctors help the patient and the family through their ordeal," he said. "Patients should not be afraid to talk to their doctor about their fears and concerns. There is no one right way to do this. Everyone is different and should be treated accordingly."