Death, futility, and oncology

With colleagues, Smith published a BMJ Christmas Editorial with the title “Death can be our Friend” in 2011.1 Since then, I have frequently pondered that philosophical topic. I broadly agree with Smith’s views about a bogus contract between doctors and patients about death.2

I also fully understand Ronchetti’s frustrations about persuading patients that treatment might not be their best option.3 The topic of imminent death is, explicitly or implicitly, on the agenda of many oncology clinic consultations. But when there is a discordance between a physician’s philosophical views and a patient’s informed choice, patients are the final arbiters of the doctor-patient contract.

Surprisingly, many patients with cancer do think palliative chemotherapy is worthwhile and actively choose to undergo toxic cancer treatments for relatively small benefits.4 Desperate people do desperate things, and patients with advanced cancer are not an exception. Multiple patient preference studies show that patients opt to prolong survival, even if only for a few months, with cytotoxic chemotherapy.5