Differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor oncology specialists

Abstract

Background: Patients with hematologic malignancies often receive aggressive care at the end-of-life. To better understand the end-of-life decision-making process among oncology specialists, we compared the cancer treatment recommendations, and attitudes and beliefs toward palliative care between hematologic and solid tumor specialists.

Patients and methods: We randomly surveyed 120 hematologic and 120 solid tumor oncology specialists at our institution. Respondents completed a survey examining various aspects of end-of-life care, including palliative systemic therapy using standardized case vignettes and palliative care proficiency.

Results: Of 240 clinicians, 182 (76%) clinicians responded. Compared with solid tumor specialists, hematologic specialists were more likely to favor prescribing systemic therapy with moderate toxicity and no survival benefit for patients with Eastern Cooperative Oncology Group (ECOG) performance status 4 and an expected survival of 1 month (median preference 4 versus 1, in which 1 = strong against treatment and 7 = strongly recommend treatment, P < 0.0001). This decision was highly polarized. Hematologic specialists felt less comfortable discussing death and dying (72% versus 88%, P = 0.007) and hospice referrals (81% versus 93%, P = 0.02), and were more likely to feel a sense of failure with disease progression (46% versus 31%, P = 0.04). On multivariate analysis, hematologic specialty [odds ratio (OR) 2.77, P = 0.002] and comfort level with prescribing treatment to ECOG 4 patients (OR 3.79, P = 0.02) were associated with the decision to treat in the last month of life.

Conclusions: We found significant differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor specialists, and identified opportunities to standardize end-of-life care.

Keywords: chemotherapy; decision making; end-of-life care; hematologic neoplasms; palliative care; quality of healthcare.

Figure 1.

Cancer treatment recommendation in the last month of life. Respondents were asked to provide their treatment recommendation using a 7-point Likert Scale from 1 (strongly against palliative systemic therapy) to 7 (strongly recommend palliative systemic therapy) for a hypothetical patient with incurable advanced cancer and a strong outspoken treatment wish. The treatment had a 15% chance of tumor response, moderate toxicity, and no expected survival gain. (A) For a patient with ECOG performance status of 4 and median survival of 1 month, hematologic specialists were significantly more likely than solid tumor specialists to favor prescribing systemic cancer therapy (median preference 4 versus 1, P < 0.0001). A bimodal distribution was observed for both hematologic and solid tumor specialists. (B) For a patient with ECOG performance status of 3 and median survival of 3 months, hematologic specialists were also significantly more likely to favor prescribing cancer therapy (median preference 4 versus 3, P = 0.0002). (C) For a patient with ECOG performance status of 2 and median survival of 6 months, no difference was found (median preference 5 versus 5, P = 0.18).