OncologyTier 2Topic

End-of-life decision making

Principles

End-of-life decision-making in oncology centres on aligning treatment with the patient's goals, values, and prognosis, particularly as disease-directed treatment options narrow
A substantial proportion of patients receive aggressive treatment (chemotherapy, ICU admission) very close to death, often reflecting delayed or absent goals-of-care conversations rather than patient preference

Prognostic uncertainty and clinician reluctance to discuss dying are recognised barriers to timely goals-of-care conversations - patients and families frequently report wanting more, not less, honest discussion about prognosis than they receive

Recognising the transition point - declining performance status, rapid disease progression despite treatment, or a patient's own expressed readiness to stop disease-directed therapy - should prompt a proactive conversation, not one delayed until a crisis

Advance care planning (resuscitation status, preferred place of death, substitute decision-maker/enduring guardian) should be addressed before a crisis, ideally alongside ongoing disease-directed treatment rather than only once treatment options are exhausted
Early palliative care integration (alongside, not instead of, active treatment) has been shown to improve quality of life and, in some studies, survival in advanced cancer
Stopping disease-directed treatment is a distinct decision from stopping all treatment - symptom-directed care continues and often intensifies

Refractory symptoms at end of life (breathlessness, pain, delirium), family/caregiver support, substitute decision-making

Clear, early, honest communication about prognosis is consistently associated with better patient and family outcomes (less aggressive unwanted treatment, better quality of life, less complicated grief) than delayed or avoided conversations

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