Over the past three years, Sharon, age 38, has been intermittently receiving treatment for ovarian cancer. She was initially treated with carboplatin and paclitaxel and remained in remission for 20 months. She responded well to second-line therapy (carboplatin, gemcitabine, and bevacizumab), remaining on bevacizumab maintenance until she experienced a relapse eight months later.
Sharon presents to the infusion room for third-line treatment with single-agent topotecan. She appears exhausted and has lost 20 lbs. since she was last in treatment. Sharon tells her oncology nurse, Jenny, that she has been requiring a paracentesis more frequently but her attitude remains positive. Jenny is concerned when Sharon says, “I sure hope this new treatment will get rid of this cancer for good.”
What Would You Do?
People with advanced cancer often misunderstand that when a treatment is palliative, it is not considered curative. A large study (N = 1,193) evaluating patients with advanced lung and colorectal cancer revealed that 69% of the patients with lung cancer and 81% of the patients with colorectal cancer did not understand that the treatment was not considered curative. In a smaller study (N = 125), 25% of patients did not fully understand cure versus noncure goals of care. Additional research identified that despite physicians attempting to provide an accurate assessment, they frequently overestimated both survival (30%) and prognosis (fivefold).
The Institute for Healthcare Improvement (IHI) and the Conversation Project developed the Conversation Ready Toolkit for Healthcare Providers that uses open-ended and rating questions to prompt conversations about what matters most to the patient. It guides the user in creating a safe atmosphere for having delicate discussions about end-of-life care.
Because Jenny recently completed the IHI course Basic Skills for Conversations About End of Life, she feels confident asking Sharon to explain her understanding of the treatment goal. Sharon replies that she worries about jinxing a possible miracle if she acknowledges that the chemotherapy is only to extend her life. Jenny asks Sharon what she feels could be helpful to her at this time. Sharon acknowledges that talking with a chaplain might help. The chaplain meets with Sharon and follows the Conversation Ready principles to guide their discussion.