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Author RSH (a palliative medicine physician) was asked to see a patient with a newly diagnosed metastatic cholangiocarcinoma and Eastern Cooperative Oncology Group (ECOG) performance status grade 3. The oncologist prefaced the consultation saying ‘[The patient] has no good chemo(therapy) options. I think he needs hospice.’ After consultation, RSH and the patient agreed on home hospice. The oncologist saw the patient later that day and told RSH, ‘Well, I’ve decided to give him chemo, because if I don’t give chemo, then someone else will.’
Great advances in the prevention, detection and treatment of cancer continue to improve survival. However, despite much attention focused on end-of-life chemotherapy, many patients continue to receive chemotherapy late into their illness, providing minimal benefit and potentially causing harm. In this article, we describe the prisoner’s dilemma, in the context of palliative oncology, as a framework to partially explain this finding. We believe that this novel perspective will provide valuable and interesting insights to practising clinicians.
Almost 10% of patients receive chemotherapy within 2 weeks of dying of cancer, and 60% receive treatment within 2 months of death.1 The majority of these patients mistakenly believe that this type of chemotherapy is curative rather than palliative.2 In fact, end-of-life chemotherapy has limited benefits and is associated with worse quality of life, more emergency and intensive care interventions and greater financial cost to patients and families. Consequently, the American Society for Clinical Oncology identified reducing end-of-life chemotherapy as one of the ‘top five’ practices for improving care and cutting costs. Despite these recommendations, large number of patients continue to receive aggressive treatment within their last few days of life.3
Why do patients continue to receive end-of-life chemotherapy? We believe that ‘inappropriate’ chemotherapy at end-of-life does not result from poor decision-making by oncologists. Instead, it is partially driven …
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