title: Framework for timing of the discussion about forgoing cancer-specific treatment based on a qualitative study with oncologists.
abstract: BACKGROUND
  Many patients with advanced cancer receive aggressive chemotherapy close to death and are referred too late to palliative or hospice care.
  
  
  OBJECTIVE
  The aim of this study was to investigate oncologists' and oncology nurses' perceptions of the optimal timing for discussions about forgoing cancer-specific therapy at the End-of-Life (EOL) and the reasons that might hinder them.
  
  
  METHODS
  Qualitative in-depth interviews with oncologists and oncology nurses were carried out. The empirical data were evaluated from a normative perspective.
  
  
  METHODS
  Twenty-nine physicians and nurses working at the Department of Hematology and Oncology of a German university hospital were interviewed.
  
  
  RESULTS
  Health-care professionals differed considerably in their understanding of when to initiate discussions about forgoing cancer-specific therapy at the EOL. However, their views could be consolidated into three approaches: (1) preparing patients gradually throughout the course of disease (anticipatory approach) which is best suited to empower patient self-determination in decision-making, (2) waiting until the patient him/herself starts the discussion about forgoing cancer-specific treatment, and (3) waiting until all tumor-specific therapeutic options are exhausted.
  
  
  CONCLUSIONS
  The empirically informed ethical analysis clearly favors an approach that prepares patients for forgoing cancer-specific therapy throughout the course of disease. Since the last two approaches often preclude advance care planning, these approaches may be less ethically acceptable. The proposed framework could serve as a starting point for the development of concrete recommendations on the optimal timing for EOL discussions.
authors.affiliation: Department of Medical Oncology, National Center for Tumor Diseases (NCT), Programme for Ethics and Patient-oriented Care, Heidelberg University Hospital , Im Neuenheimer Feld 460, 69120, Heidelberg, Germany, katsiaryna.laryionava@med.uni-heidelberg.de.
authors.forename: K
authors.initials: K
authors.lastname: Laryionava
authors.forename: P
authors.initials: P
authors.lastname: Heußner
authors.forename: W
authors.initials: W
authors.lastname: Hiddemann
authors.forename: E C
authors.initials: EC
authors.lastname: Winkler
mesh_terms: D032722:Advance Care Planning / Q000592:standards; D001291:Attitude of Health Personnel; D003657:Decision Making; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009369:Neoplasms / Q000628:therapy*; D009726:Nurses; D010465:Perception; D010820:Physicians; D036301:Qualitative Research; D013997:Time Factors