DISCUSSION

Beliefs of doctors and the anti-cancer therapy process

In this study, we identified two beliefs held by doctors who treat recurrent/metastatic breast cancer—the acceptance belief and non-acceptance belief—and created a model for the treatment process and communication shaped by differences in these beliefs. Pirl et al categorized the process of terminating chemotherapy in the terminal stage into (1) a final decision to clearly terminate treatment, (2) an ambiguous termination of treatment through postponement of the decision, and (3) a “non-decision” that leaves treatment terminated.10 Doctors of the present study who held the acceptance belief followed (1), whereas doctors with the non-acceptance belief almost always followed (2) or (3). The research by Pirl et al, however, merely classified patterns. The present study is unique in that it clarified the underlying unconscious thoughts of doctors.

Overprotection model in patient-doctor relationships


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Among doctors who held the non-acceptance belief, there were those who, not wanting to hurt patients, inferred that the intent of patients was a “desire for treatment” and thus continued to propose treatment options. Doctors taking this approach consistently throughout the process of treating patients with recurrent/metastatic breast cancer may have hindered the psychological growth of patients because, if they had adequately discussed the issues during the process, patients may have come to accept and understand death. This resembles the type of overprotection that occurs when mothers obstruct their children’s process of growth and autonomy in order not to harm them. In this study, we refer to this type of patient-doctor relationship as “the overprotection model”.

One model of patient-doctor relations in which doctors make decisions against patient wishes or by inferring intent is paternalism, but “the overprotection model” is different. Paternalism can be divided into “hard paternalism” in which doctors know the patient’s intent but go against it nonetheless, and “soft paternalism”, when doctors do not know the patient’s intent but they or patient family members make decisions thought to be best for patients.11 In the overprotection model we propose, doctors impede patient growth. Doctors make decisions based on their unconscious beliefs, as they do not believe the patient’s ability to grow, and deny the possibility of growth through the process of facing a good death. In other words, the doctor’s stance is not to deny the patient’s intent, but to deny growth of the patient as a human, which differs from traditional paternalism.

If, under the overprotection model, the patient’s idea of a good death is to die without facing death, and this matches what doctors infer is a good death, then this model could be beneficial. Some have noted, however, that there may be patients who, even though they display nothing but rejection or anger when initially diagnosed, will come to grow, achieve autonomy, and accept death through the process of interacting with their doctors.12,13 Although this study did not delve into the drawbacks of adopting the overprotection model, we believe they would be substantial. Future studies that examine the effects of the overprotection model and include patients and bereaved family members as participants are warranted.

Clinical implications

Table 2 shows the 10 categories identified in this study, which serve as clues as to which belief the doctors themselves hold when they approach treatment. Based on whether there were more As or Bs, we considered it possible to determine that a doctor’s beliefs were closer to “acceptance” for A or “non-acceptance” for B (though there may of course be doctors who hold both beliefs). Below we describe notable points for each belief.

(To view a larger version of Table 2, click here.)

For doctors closer to the non-acceptance belief

Doctors with the non-acceptance belief tended to avoid talking to patients about death, because they thought it would cause suffering. It is possible that, for individual patients, these doctors were unable to acquire information about what the patient considered a “good death”. Although it might be difficult to share accurately the patient’s idea of what constitutes a good death, the sense that doctors understand their thoughts is a major source of support for patients. In recent years, Advance Care Planning (ACP) has broadened ways of not only sharing patient intentions about treatment, but even sharing their value systems. There have been reports that ACP has increased the satisfaction of terminal patients and their family members.14 Thus, the sharing of values, not only through ACP, could provide valuable support to patients.

Disclosing bad news on disease outlook, including death, is a difficult and stressful kind of communication for doctors.15–17 Particularly when a doctor is in charge of the care of a single patient over a long period, it can be very difficult for them to discuss the terminal stage.16 Temel et al reported that when discussing terminal stage care, an introduction to the palliative care team can be a valuable source of support.18 For doctors who resist discussing end of life, promptly informing patients about the palliative care team, and letting patients know about preparations to coordinate treatment with palliative care team, can potentially relieve doctors’ stress around disclosing around bad news.

For doctors closer to the acceptance belief

Among doctors with the acceptance belief, there were a few whose values strongly insisted that only by accepting death could patients meet a good death, and thus they appeared not to address individual differences in what a good death might mean. In a previous qualitative study on patients with metastatic breast cancer, some patients were found to be overwhelmed by the fear of death, see treatment as a lifeline, and hope to continue treatment for as long as possible in order to forestall death.19 There is also a report that for some cancer patients, treatment is used as a form of life support and way of coping with the fear of death; when treatment is stopped, it eases the strain on the body, but leaves emotional stress.20 That study also suggested that continuing chemotherapy at a dosage that would not impact the patient physically might offer salvation to such patients. In cases where patients absolutely desire to continue treatment even after discussions, it may be prudent to examine how to respect the patient’s conception of a good death.

Limitations

This study has some limitations. First, because we did not survey the views of patients or bereaved family members, we could not determine the impact of the treatment process or doctor’s thinking on their QOL in the terminal stage. In this regard, surveys that include patients and family members and assessing their connection to the treatment process and doctor’s way of thinking would be informative. Second, the present study is a qualitative study focused on Japanese breast surgeons, and the results are dependent on Japanese treatment practices and individual contexts. For this reason, gauging the generalizability of these results in other medical cultures and contexts will require an expanded scope, for example global quantitative research. By drawing from the rigorous procedures of the Grounded Theory Approach, however, this study has elucidated the target phenomenon in great detail.

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