Inside research

Chemotherapy at end of life

by Andrea Butler

When is enough chemotherapy enough?

Thomas J. Smith, M.D.
Thomas J. Smith, M.D., F.A.C.P.

Chemotherapy toward the end of life may not be the best solution for many patients with incurable cancer, according to Thomas J. Smith, M.D., F.A.C.P., the Virginia Commonwealth University Massey Cancer Center endowed professor for palliative care. His research has focused on why and how medical professionals should consider administering less chemotherapy at the end of life.

Smith’s research and clinical practice shows that less chemotherapy allows for better quality of life and easier transitions toward death for those whose illness is terminal.

Smith is co-founder and medical director of an award-winning, 11-bed inpatient palliative care unit. His program also is one of six national Palliative Care Leadership Centers, serving as a model of quality care and a training site for more than 75 other institutions.

Research shows that about 15 percent to 20 percent of cancer patients nationwide with incurable cancers receive chemotherapy within 14 days of their death. At that stage, when the disease has progressed and patients are often failing, the chemotherapy has virtually no chance of helping.

Chemotherapy“As doctors we are taught to save lives, and much of our training and practice is geared toward that effort,” said Smith, who is the medical director of the Thomas Palliative Care Unit. “Patients and their families want and need more information to transition toward the best death possible.”

In the June 2008 issue of the Journal of the American Medical Association, Smith cited factors to be considered before administering chemotherapy at the end of life include:

  • Negative side effects compromise the patient’s sense of well-being.
  • People in hospice not receiving chemotherapy live longer.
  • Chemotherapy prevents patients from going into hospice.
  • One in three families is bankrupted by serious illness.
  • Patients receiving chemotherapy are likely to miss opportunities for spiritual growth, quality family time, travel, financial transitions and to pass on a “life review” for future generations.

The authors show that chemotherapy is given near the end of life in the U.S. more than in other countries. The contributing factors include:

  • Patients experience lack of honest information about their prognosis.
  • Hype from drug companies and national research organizations can lead to inaccurate information.
  • People don’t believe their doctors or have a different perspective.
  • Doctors and patients want to avoid frank discussion about the issue.
  • Doctors in the U.S. are paid to prescribe chemotherapy; they are not paid to counsel patients and help them prepare for a “good death.”