|E.J. Emanuel, MD, PhD, Department of Clinical Bioethics, National Institutes of Health, Bethesda, Md, highlighted the 1997-98 mail survey on some 8,700 members of the American Society of Clinical Oncologists (ASCO). There were 149 multiple-choice questions and 4 patient vignettes on EOL issues of cancer patients. About 3000 (35%) of the ASCO members participated. The respondents were primarily urban, males, oncologists in academia or group practice, and extremely busy. Oncologists, according to the survey, need an improved comfort level in communicating with dying patients and in shifting to palliative care. ASCO faces the challenge of providing members with training to master the required skills.|
|Characteristics of surveyed members|| Emanuel described the sample as:
|Learning about EOL care||According to the survey results, the top four ways that oncologists learn
about EOL are:
More recent medical school graduates received some EOL care training as a formal course or during clinical rotation. Nevertheless, fewer than 20% of the oncologists who graduated in the 1990s reported formal EOL training in medical school and only 50% received such information during postgraduate training.
|Self evaluation of competency||This survey showed >90% of the responding oncologists perceive themselves as having "a lot" of expertise in managing pain, constipation, nausea/vomiting, fever, and neutropenia in EOL cancer patients. They report much less ability in treating depression especially and loss of appetite. In Emanuel's opinion, one barrier to learning new EOL skills may be the high sense of competency in pain management. (The unpublished Foley survey at NY Memorial Hospital found some 25% of EOL cancer patients still in pain).|
|Communicating with terminally ill patients||
The Emanuel survey tabulated responses to such important questions as:
|Barriers to caring for the dying||
The data show that oncologists believe very important barriers to good EOL
care are unrealistic patient/family expectations and family conflicts.
Oncologists anxious about telling patients they will die reported having
unrealistic expectations compared with good communicators. Only 10% of
the US-surveyed oncologists found patient resistance to taking opioids or
federal/state regulations of opioids as problematic.
Healthcare delivery represents a serious barrier in the US, according to questionnaire responses:
Other serious barriers include lack of time to discuss EOL concerns and limited availability of unskilled home care or hospice services.
|Chemotherapy and EOL||Which oncologists prescribe chemotherapy for terminally patients? The present data point to practitioners >50 years old and persons who experience a sense of failure when the patient becomes terminally ill. Surgical oncologists seemed most likely to prescribe chemotherapy rather than palliative care. Only 20% of the respondents provide hospice care after second-line chemotherapy.|
|Vignette: patient with unremitting pain||
One of 4 vignettes covered a breast cancer patient in pain although on
iv morphine. What should be done? Here are the survey responses:
|Euthanasia and physician-assisted suicide (PAS)||Twenty-two percent of responding oncologists found PAS ethically acceptable and 15% would be willing to do it. Corresponding figures for euthanasia were lower, 6.5% and 2.5%, respectively. Others reporting more support for PAS were less religious or surgeons. Oncologists who have more time to talk to the patient, Catholic, or possess poor pain management skills found PAS and euthanasia less acceptable.|
|Presenter conclusions||Emanuel's conclusions are based on a preliminary analysis of the data which will be refined for publication. The survey results show a need to improve the comfort level of oncologists in communicating with dying patients, especially in shifting to palliative care. ASCO should provide members with training to master the required skills identified by this survey. One benefit could be a decreased use of third- and fourth-line chemotherapy in the terminally ill.|
Presented at the American Society of Clinical Oncology (ASCO) Meeting,
May 16-19, 1998
Copyright © 1998 Conrad Group Inc. All Rights Reserved
Eugene A. Conrad, PhD, MPH / ISSN 1078-2230 / June 1998
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