Is shared decision-making vanishing at the end-of-life? A descriptive and qualitative study of advanced cancer patients’ involvement in specific therapies decision-making

BMC Palliative Care

Research Article

Eric Deconinck¹  Christophe Tournigand²  Régis Aubry³  Yvan Beaussant³  Patrice Cuynet⁴  Aurélie Godard-Marceau⁵  Aline Chassagne⁵  Hélène Trimaille⁵  Lionel Pazart⁵  Elodie Cretin⁶  Florence Mathieu-Nicot⁷  Carole Bouleuc⁸  Serge Daneault⁹ 

[1] Besancon University Hospital, Hematology, 2 Bd Fleming, 25000, Besancon, France;Department of Oncology, Henri Mondor University Hospital, 51, avenue du Mal de Lattre de Tassigny 94010, Créteil cedex, France;Department of Pain Management – Palliative Care, Besancon University Hospital, 2 Bd Fleming, 25000, Besancon, France;Inserm CIT808, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Ethics Centre of Burgundy and Franche-Comté, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Department of Psychology of Besancon, University of Franche-Comté, 2 place St-Jacques, 25000, Besancon, France;Inserm CIT808, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Inserm CIT808, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Ethics Centre of Burgundy and Franche-Comté, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Inserm CIT808, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Ethics Centre of Burgundy and Franche-Comté, Besancon University Hospital, 2 place St-Jacques, 25000, Besancon, France;Department of Psychology of Besancon, University of Franche-Comté, 2 place St-Jacques, 25000, Besancon, France;Inter-Disciplinary Supportive Care Department for the Oncology Patient, Institut Curie, 26 Rue d’Ulm, 75005, Paris, France;Palliative Care Unit, Notre Dame Hospital, Montréal University Hospital (CHUM), Montreal, Canada;

关键词: Neoplasms;    Decision making;    Uncertainty;    Ethics;    Physician-patient relations;    Defense mecanisms;    Withholding treatment;    Advance care planning;    Chemotherapy;    Palliative care;   

DOI  :  10.1186/s12904-015-0057-4

 received in 2015-07-30, accepted in 2015-11-06,  发布年份 2015

来源: Springer

【 摘 要 】

BackgroundLittle is known about what is at stake at a subjective level for the oncologists and the advanced cancer patients when they face the question whether to continue, limit or stop specific therapies. We studied (1) the frequency of such questioning, and (2) subjective determinants of the decision-making process from the physicians’ and the patients’ perspectives.Methods(1) All hospitalized patients were screened during 1 week in oncology and/or hematology units of five institutions. We included those with advanced cancer for whom a questioning about the pursuit, the limitation or the withholding of specific therapies (QST) was raised. (2) Qualitative design was based on in-depth interviews.ResultsIn conventional units, 12.8 % of cancer patients (26 out of 202) were concerned by a QST during the study period. Interviews were conducted with all physicians and 21 advanced cancer patients. The timing of this questioning occurred most frequently as physicians estimated life expectancy between 15 days and 3 months. Faced with the most frequent dilemma (uncertain risk-benefit balance), physicians showed different ways of involving patients. The first two were called the “no choice” models: 1) trying to resolve the dilemma via a technical answer or a “wait-and-see” posture, instead of involving the patients in the questioning and the thinking; and 2), giving a “last minute” choice to the patients, leaving to them the responsibility of the decision. In a third model, they engaged early in shared reflections and dialogue about uncertainties and limits with patients, proxies and care teams. These schematic trends influenced patients’ attitudes towards uncertainty and limits, as they were influenced by these ones. Individual and systemic barriers to a shared questioning were pointed out by physicians and patients.ConclusionsThis study indicate to what extent these difficult decisions are related to physicians’ and patients’ respective and mutually influenced abilities to deal with and share about uncertainties and limits, throughout the disease trajectory. These insights may help physicians, patients and policy makers to enrich their understanding of underestimated and sensitive key issues of the decision-making process.

【 授权许可】

CC BY   
© Beaussant et al. 2016