Oncologists stress the evidence, but breast surgeons want to provide patients with any treatment that would not do harm. There are also patients who want to try any treatment if it might have some effect. (ID 11)

At this point, doctors with the non-acceptance belief felt a resistance to discussing prognosis, and rarely shared the prognosis with patients. Doctors with the acceptance belief, however, were prepared to discuss all bad news, and at times shared an outlook on prognosis with patients.

If patients want to know how long they have left (prognosis), I feel I should tell them how long I think they have to live. (ID2)

Step3A


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Step 3 comes into play after failing the fifth line of treatment, and doctors already predict that the next treatment would not be effective. At this step, doctors with the non-acceptance belief continued treatment in order to satisfy patients, hoping the treatment would have a positive psychological effect (Step 3A). At this stage, doctors stressed satisfying patients by continuing treatment, rather than the effect of the chemotherapy itself.

The point of treatment is to give peace of mind, for the patient’s sake. (ID21)

Because doctors at this stage emphasized patient safety, they administered a reduced dosage when the patient’s physical condition was bad, even if it weakened the anti-cancer effect. At this stage, continuing treatment is thought to have the psychological effect of offering salvation to maintain hope, or to help patients understand through experience that their condition is progressing and that treatment will no longer have an effect.

‘We did all we could, but it didn’t work; there’s nothing more to do,’ I want patients to come to that conclusion on their own. (ID4)

Furthermore, participants believed that fulfilling the wishes of patients would also satisfy the doctor. In the backdrop of this was the desire to live up to their ideal vision of the doctor as one who can fulfill patient hopes by always proactively proposing treatments. These doctors were confident that a surgeon could manage pain relief and end-of-life care. In addition, when continuing to diagnose and treat patients they had operated on, as surgeons, there was a sense of guilt at having allowed the cancer to return, and a feeling of powerlessness at being unable to heal it, leading them to insist on further chemotherapy. For this reason, they believed that the mission of doctors is to support the life of patients until the very end, motivating the continuation of treatment.

When cancer returns in patients I operated on, I feel guilty. That’s why I want to do something (chemotherapy) for them. (ID18)

Among these doctors, there was a tendency to avoid clearly confirming patient intent regarding treatment, out of a sense of resistance toward convincing the patient to give up treatment. Inferring the desire of patients to continue treatment, they suggest it as long as patients did not refuse, or alternatively did not recommend treatment but conveyed this in a way that left room for continuing treatment.

As long as they don’t say they want to stop, we keep proposing options. (ID7)

Even when patients ask about prognosis, these doctors often did not clearly share it to avoid hurting them. Reasons for this included the difficulty of prognosis in breast cancer, or that it was not necessary to inform patients because they should have already realized, or that doctors hope the patients would guess the prognosis on their own during the course of treatment.

When continuing the treatment of metastasis or recurrence, I think patients probably know that it’s natural that the treatment will stop working, and realizes that this is harsh, and risky. So, as a doctor, I think, ok, it’s time to notice the signs. (ID9)

These doctors, however, sometimes looked back at the results of continued treatment at this stage and regretted the decisions made, wishing they had not gone through with the final treatment.

You wonder if it might have been better not to proceed with that last treatment. (ID4)

Step3B

On the other hand, doctors with the acceptance belief terminated treatment for the sake of allowing patients to have a good death (Step 3B). These doctors drew on information gleaned from discussions with patients until that point, and when it seemed highly likely that the next treatment would make it impossible for them to have a good death, they would propose giving up on treatment in favor of palliative medicine.

If we pursue treatment, there is the possibility that patients might not be able to do the things that are most precious to them, so I let them know that it’s better not to do it (anti-cancer therapy). (ID16)

Many patients accepted such proposals, and anti-cancer therapy was terminated to focus solely on palliative medicine, so that the case does not progress to Step 4. When patients had difficulty accepting death, and strongly requested that treatment be continued, doctors respected these intentions and attempted treatment for a limited period. When treatment was found not to be effective, however, these doctors proposed terminating treatment, and almost all patients accepted this.

If someone really wants to continue, I say ok, let’s do our best. But this is the last thing we’ll do, I explain. I tell them that if this doesn’t work, we quit. (ID15)

Some doctors with the acceptance belief had this kind of experience with patients: as a result of their attempts to persuade a patient to terminate anti-cancer therapy and focus on palliative care, the patient stops coming to the hospital and transfers to a different hospital in order to continue treatment.

(After even the patient mentioned wanting to proceed with treatment) The husband asked me to ‘just go on and do it for her.’ I explained that it was better to value the time remaining (rather than continuing treatment), but they said, ‘Fine, we will go to another hospital,’ and the patient died just one month after transferring. (ID17)

Step4

When the illness worsened to the point that chemotherapy would be dangerous, doctors with the non-acceptance belief decided they could not perform treatments that would only harm patients, and paused treatments in order to avoid harm (Step 4).

At this time, while doctors sometimes told patients they could not offer any more treatment, they did show a sense of consideration to protect patients from the harsh reality of facing death, and so framed their proposal as “Let’s take a break from treatment for a bit.” This allowed patients to maintain hope that treatment would be re-initiated, while effectively ending treatment.

When treatment was virtually impossible to continue, I would say something like ‘Why not take a little break?’ This is different than saying that no more treatment would be performed. (ID6)

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