Two beliefs about accepting death
The process by which the chemotherapy of patients with recurrent/metastatic breast cancer was continued and terminated differed based on two beliefs held by doctors (Figure 1). One of these is a “belief that the patient is an entity who cannot accept death” (hereafter “non-acceptance belief”). Doctors with the non-acceptance belief maintained that bad news could harm patients, focused first only on discussions of anti-cancer therapy, and avoided any discussions that might suggest death. They proposed treatments as long as options were available, and ultimately when it was determined that the patient’s physical condition could not bear further treatment, they ended it in order to avoid doing harm, although they kept patients still hoping for continued treatment. The other is a “belief that the patient is an entity who can accept death” (hereafter “acceptance belief”). Doctors with this belief provided patients with an overview of their conditions early on following the diagnosis of recurrent/metastatic breast cancer. They repeatedly prepared patients for bad news about the progression of the illness or termination of treatment from early in the treatment process, and ultimately, when they judged that administering the next treatment would make it impossible for patients to achieve their own good death processes, they proposed terminating treatment.
Non-acceptance belief narratives
First, doctors with the non-acceptance belief considered patients unable to accept death, and avoided discussions with patients that involved confronting death.
For Japanese people, I think it’s hard to end life in a way that simply accepts death. There are few who have the strength to face death, and even fewer doctors who are willing to accompany them as they do so. (ID8)
Many had a sense of powerlessness and guilt toward patients whose cancer relapsed after they performed surgery, and thus, as surgeons, were adamant about continuing chemotherapy. They stated that, as the person who understands patients the best, they wanted to continue to be in charge of their care until the very end. This kind of doctor believed that it was the surgeon’s mission to continue to support the life of patients with treatment.
My feeling is that really the stance of the surgeon is to be proactive about surgery and to always think about how to do things better. (ID7)
Acceptance belief narrative
On the other hand, doctors with the acceptance belief considered patients to be able to accept death, and aspired for communication that would support patients as they face death. They believed that the relationship of trust with patients required a sharing of an overarching perspective on the disease that included death.
By giving patients some picture of what the illness will be like in advance, I think they can make their own judgments, or maybe by doing that, even when I have to give them bad news, they would be able to accept it. (ID15)
Furthermore, this group believed that the doctor’s mission was to keep supporting patients so they could experience a good death. They believed it most important to ensure that patients are able to spend their final days as they wish.
It (the doctor’s goal) is all about finding how we can support patients during the time they have left before they die. (ID12)
Four steps for decision-making process of chemotherapy for advanced breast cancer patients
In Step 1, the doctor continues treatment to prolong life. When recurrence/metastasis is diagnosed, the first treatment option is chemotherapy, unless hormone therapy is indicated. Regardless of their beliefs, many doctors encouraged patients to undergo treatment, believing there is evidence that the initial treatment (first through third line treatment) prolongs life.
At this stage, doctors with the non-acceptance belief conveyed to patients that the illness will not get better, but many prioritized discussing specific anti-cancer therapies, rather than sharing an overview of the illness, which includes death.
When it recurs, I first discuss the necessary anti-cancer therapy. (ID14)
On the other hand, doctors with the acceptance belief shared with patients an overview of the illness that implies death will inevitably come, in order to build a relationship of trust with patients.
I make it a point to clearly tell them that if the cancer comes back, they will die eventually. Maybe I do this to avoid any misunderstanding. (ID12)
In Step 2, treatment is continued in order to test its potential efficacy. In the case of breast cancer patients, physical condition is often good even after failing the fourth line of treatment, and although the evidence of their efficacy is inadequate, multiple treatment options exist. Doctors, however, out of mistrust of current evidence or a belief that any drug approved and covered by public medical insurance must have at least some minimal effect, entrusted their hopes to any therapy that has a non-zero chance of working, and continued treatment.
It’s not as if there’s evidence that the treatment will never work. (ID15)
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