Saturday, June 22, 2013

Saying no to chemotherapy by Des Spence - BMJ

“Dad: eggs and salt are bad for you, teacher says.” “Nonsense: you mustn’t believe everything you are taught at school.” There is an art to poaching eggs, and I have one with salt every day for breakfast. I ignore health scares about food, because the more health conscious people are the more miserable they seem to become. Likewise, the benefits of screening or health check ups make no intuitive sense to me. So, on a personal level, I happily ignore the advice of “experts.” Risk is about judgment, and you can be too careful. Life is for living.

But saying no to patients isn’t so easy. They trust doctors: “Whatever you think, doctor.” Likewise, doctors are cuffed by guidelines, telling us to intervene even when we think we shouldn’t. No doctor is criticised for doing too much; the easy thing is always to intervene. So doctors spectate on the march of medicalisation, overdiagnosis, and overtreatment. History will judge our era as one of iatrogenic harm.

And this is a problem with cancer treatments. There have been great advances in treatments and survival (partly because of overdiagnosis of non-progressive disease). And if cancers cannot be cured then many can be contained. But there are unresponsive solid tumours and metastatic disease for which chemotherapy becomes merely palliative, and the prolongation of life is short, if it happens at all. But patients are offered ever more chemotherapy. Most, however, are unaware that it has limited benefit.1 This is wrong.

Chemotherapy involves frequent attendance at hospital, admission, surgical lines, and infusion or transfusion. Patients are put off travelling or seeing family as a consequence. Also, chemotherapy makes patients feel unwell—some mildly, some badly—and is occasionally fatal. Patients become ensnared in the hospital system, often dying in hospital and not at home as many would wish. Worse, it offers false hope. Death is sad, but it must be borne and normalised. Palliative chemotherapy steals away the most precious time.

So why use chemotherapy when it is worse than futile? Perhaps because there is pressure from families and patients “to do something.” Perhaps the media peddle unrealistic expectations. Perhaps patients are on a depersonalised conveyor belt of intervention. Perhaps because of fear of taking away hope. Perhaps doctors are too afraid to talk about death, which we see as professional failure. Certainly, its use is a consequence of a lack of continuity across hospital and general practice. And certainly, it is easier to offer treatment than not. We need to support dignity in death, and this often means saying no to chemotherapy. There is an art to medicine—that is, knowing when to intervene but more importantly knowing when not to too.


Cite this as: BMJ 2013;346:f4023


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Follow Des Spence on Twitter @des_spence1


  1. Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med2012;367:1616-25.

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