Oncologists say they are encouraged to overprescribe high cost medicines at the end of life by a PBS system that makes it easier to offer false hope than have a difficult conversation with patients about stopping futile treatment.
Healthcare ethics researchers who interviewed 16 Australian haematologists and oncologists found a common theme was that drug registration and reimbursement systems create an environment in which the imperative is to keep offering end-stage cancer patients the latest medications even when these may have little benefit and treatment has negative effects on quality of life.
While acknowledging that individual clinicians have difficulty initiating conversations with patients about dying, the researchers from Sydney University found this was compounded by socio-cultural factors that make death a taboo subject and society’s beliefs in the benefits of biomedical technology to prolong life.
Several clinicians said the availability of new drugs and the desire to provide hope for patients could lead physicians to prescribe a fourth or fifth line of therapy in hospital rather than talk to patients about quality of life off treatment, and a dignified death at home .
“Doctors tend to want to provide another agent because the discussion with a patient around palliative care is more difficult than saying I’ve got a new drug for you,” said one participant.
“It is much easier for me to say to a patient, let’s just try this and come back and see me in a few weeks, when I know it’s not going to work … rather than having the hard conversation to say your treatment’s not working,” said another.
Several clinicians said physicians need to be better equipped to resist the expectations from within the profession – and pushed by the pharmaceutical industry – to keep treating the patient whatever the cost, rather than manage their expectations.
Clinicians were particularly critical of cancer clinical trials and reimbursement criteria that result in high cost medications being made available at the end of life rather than earlier in disease, when they are more likely to be effective.
“Because early phase studies are done in patients with end stage disease, in order to get the data needed to bring the drug upfront where it’ s actually going to make a difference to overall cure rate, the drug stupidly … then gets marketed for end stage disease,” said one participant.
“That’ s ridiculous. … the way to cure them is to [treat] them at a much earlier stage.”
However, others said the rapid pace of change in cancer research left clinicians offering new treatments for which they did not fully understand the benefits, limitations and adverse effects.
“The increasing problem . . . with this explosion of new agents . . . [is that] we don’ t know which one to use when, we don’ t know which one’ s going to be the best in what situation. So, to a large degree we are flying blind,” they commented.
The authors of the study say their interviews show that clinicians recognise there is a problem with inappropriate prescribing at the end of life, and that this is driven by a wider range of factors beyond physician-patient communication.
“It follows that we need to understand how these influences interact, and take them into account in designing public policy and clinical interventions to address inappropriate prescribing,” they conclude.
The findings are published in the journal Sociology of Health & Illness.