For decades in American medicine, when it came to treatment, the default position seemed to be that everything that could be done for the patient should be done. Despite that such treatment often proved to be futile and costly, particularly in end-of-life circumstances, the prevailing notion was to do everything that was possible to save the patient.

I am always interested in new developments that give insight into the evolution and refinement of the practice of medicine. One recent paper1 made me think that perhaps we are rethinking this prevailing notion. It may mark a maturing element of medical practice when we recognize that more treatment is not always better for patients or their families.

Cancer's Wide Reach

Most of us who are in the final third of our lives have been touched by cancer. Cancer is a modern reality of all medical practice. We are all affected by this disease in both our personal and professional lives. Lawrence M. Herman, MPA, PA-C, a fellow PA educator, wrote a moving account of his reactions when his wife, Debbi, was diagnosed with advanced breast cancer.2

I think of my own experience as a young PA five years out of my training in 1979, when my wife, Bobbi, was diagnosed with colon cancer at age 34, shortly after the birth of our second child. I was on the faculty of Johns Hopkins at the time, and like the Hermans, we sought and obtained the most advanced therapy available. The experience was beyond frustrating and disheartening. I'm sure that hundreds of my colleagues have been similarly affected and know from personal experience how difficult these situations are.

Our health care system and the common pattern in medical practice, unfortunately, are still oriented to aggressive, often futile attempts at care. Physicians typically are trained to employ all of the arrows in the medical quiver. In the early stages of a disease like cancer, this is the approach that all involved parties want in the hopes of a cure or prolonged period of survival. Yet in a disease as unremitting as cancer, such approaches work only part of the time. As the disease progresses in some patients, it becomes more difficult on the patient as well as the clinician. Numerous studies show that physicians often avoid detailed or lengthy discussions near the end of life or when treatment fails and often are overly optimistic about prognosis.3 Some suggest that these behaviors are attributable to the clinician's own feelings of failure or loss.

Aggressive Care May Be Ineffective

This study, which I think is noteworthy, was a trial of 332 patients with advanced cancer and their informal caregivers. Funded in part by the National Cancer Institute, it was a prospective, multisite, longitudinal cohort investigation labeled "Coping with Cancer." The major outcomes measured were aggressive medical care (e.g., ventilation, resuscitation) and hospice in the final week of life; secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

Over a six-year period of observation, results revealed that end-of-life discussions were associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment. Sadly, more than 60% of patients in this study could not recall having had end-of-life discussions with their physicians.

It is often said that PAs are regarded as clinicians who possess superior clinical skills, particularly in patient communication, although the literature supporting this assertion is old and scattered. It would be interesting to know whether PAs were any more effective than physicians in conducting end-of-life discussions with terminally ill patients. We certainly know that PAs are in an ideal position to employ such communication techniques and to advocate, for example, for hospice care versus more aggressive approaches in end-of-life care. Such clinical approaches surely would make a big difference to patients and their families in coping with cancer and in dealing with the choices of doing more or less. I suspect that many PAs subscribe to the enlightened notion that that there are times in the care of the terminally ill patient when, indeed, less is more. Let us hope that we will hear more about the practices of these clinicians, and that they will show the way in the advancement and refinement of care of cancer patients.

James F. Cawley is professor and director of the PA/MPH program at the School of Medicine and Health Sciences at The George Washington University in Washington.

References

1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008;300(14):1665-1673.

2. Herman LM. A walk through Never Never Land. JAAPA. 2007;20(6):50.

3. Fried TR, Bradley EH, O'Leary J. Prognosis communication in serious illness: perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc. 2003;51(10):1398-1403.