, 2025-04-15 16:05:00
When a patient with cancer is admitted to the hospital, the reason might not be related to the malignancy.
But the hospitalist in charge sometimes becomes aware of a major disconnect: The patient, who they just met, does not grasp the severity of their cancer prognosis.
On the one hand, the hospital medicine team and patient have advance directives and goals of care to consider, which may steer the course of the hospitalization and any use of hospice. The cancer prognosis — the patient might only have months to live, for example — could be a key component of those conversations.
On the other hand, explaining the cancer situation should fall to the oncologist, right?
“Specialists who know their patients well and have a long relationship tend to overestimate prognosis,” said David J. Casarett, MD, chief of palliative care at Duke Health in Durham, North Carolina. “Hospitalists don’t have that history and are a fresh pair of eyes. And, of course, the last time a patient saw their oncologist was probably in the clinic when the patient was relatively healthy.”
‘Always the Bad Guys’
Physicians have been wrestling with this issue for decades. They have written about it in case reports and in a guide for hospitalists who care for patients with advanced cancer.
Recently, dozens of clinicians discussed the topic on social media, prompted by a post on Reddit about a patient with metastatic colon cancer who, after nearly a month in the hospital, “remains a full code [for resuscitation] and is trying another round of chemo ‘just in case it works this time.’”
“This is a common problem, and the oncologist will never tell the patients their real prognosis. We are always the bad guys for telling them the reality,” one doctor replied.
“The crux of it is the inpatient critical illness phase is the worst time to have this discussion,” a palliative care doctor wrote. “And that’s when I’m consulted typically…”
Fundamental differences between teams and their approaches can exist.
In 2006, Casarett published a case report in the AMA Journal of Ethics describing a patient with lung cancer who experienced a series of hospitalizations, including for febrile neutropenia, a common complication of chemotherapy. The cancer had spread to the brain and bones.
The “frustrated” inpatient team and the oncologists disagreed about how best to communicate with the patient’s family, according to the report: “Despite Mr Williams’ prognosis of less than 6 months to live, the oncologists seemed unwilling to be frank in their discussions with his family, ‘not wanting to remove hope’ and pushing for an aggressive alternative treatment strategy. This is what the family would want, they reasoned. But the inpatient team knew that the family failed to understand Mr Williams’ prognosis and thus could not make a truly informed decision.”
The case report offers guidance on how to navigate this situation, like by first establishing what the prognosis is and communicating that information to the family.
To get on the same page, doctors can talk directly with each other, Casarett told Medscape Medical News. Messages through the electronic medical record can help. Another option might involve having colleagues in palliative care facilitate discussion among the healthcare professionals by bringing clinicians together or conducting “shuttle diplomacy,” he said.
“Old-fashioned fixes are the best,” he said.
Casarett and his team encourage clinicians to talk with patients about goals and preferences toward the end of life and document the discussions.
“If those conversations are clearly documented in the EHR [electronic health record], in a place where other clinicians can see them easily, it helps clinicians get on the same page,” he said. “We’ve been very successful in increasing conversations. When we started, fewer than 10% of our patients had a documented conversation in the last 6 months of life. Now that figure is more like 60%. But it’s harder to show impact on outcomes like hospice utilization or readmissions.”
Preserving Hope?
When oncologists talk about prognosis in an outpatient setting, patients’ understanding may be limited, said Melissa Loh, MD, director of geriatric hematology research at the University of Rochester Medical Center in Rochester, New York.
In one study, Loh found half of patients had an understanding of their prognosis that did not align with their oncologists’, despite a consultation.
Patients might have limited health literacy, or they might not be ready to accept the information.
For their part, oncologists might avoid being overly blunt for fear of damaging the doctor-patient relationship or hurting the patient.
Often, oncologists discuss prognosis in terms of averages or ranges, Loh said. Many patients will picture themselves at the favorable end of a curve even though that outcome is unlikely.
Some patients “really want to preserve hope,” Loh said.
Meanwhile, advertisements for medications might be another source of hope, however unfounded, that an effective treatment might be available.
When a hospitalist realizes a patient does not understand their cancer prognosis, they should loop in the oncologist and be aware that there could be a backstory to explain the disconnect, Loh said. For instance, the oncologist may have discussed the prognosis, but the patient is clinging to unrealistic expectations.
Still, oncologists should be aware if the prognostic disconnect has become a problem, and the team can weigh whether an in-hospital conversation is warranted.
Context is important. If the patient is focused on recovering from a hospitalization for an unrelated condition, it might make sense to wait to discuss the cancer prognosis in an outpatient setting, when it could be easier for the patient to process, Loh said.
Insights From Cancer Centers
Some guidance on caring for hospitalized patients with advanced cancer has come from hospitalists at cancer centers.
Douglas Koo, MD, MPH, a hospitalist at Memorial Sloan Kettering Cancer Center in New York City, and colleagues published an “experience-based guide” in 2015 — partly because they felt they had something to prove.
“We knew we were doing something special as hospitalists caring exclusively for patients with cancer,” Koo told Medscape Medical News. “Up to this point, there were some specialized hospitalist groups sharing comanagement of specific groups of patients, such as hospitalists comanaging a stroke unit with neurologists, but many believed that hospitalized cancer patients could only be adequately cared for by oncologists.”
Memorial Sloan Kettering Cancer Center established a hospital medicine service, however, and the team had a decade of experience when they published their guide in the Journal of Hospital Medicine.
“As this publication highlights, caring for a patient with advanced cancer involves coordination of care,” Koo said. “Hospitalists are experts at hospital-based care processes, communication, and organizing care between a patient’s oncologist, consultants, social work, case management, and many others to improve the quality of care that these patients receive.”
Not all hospitals will have the specialized procedures or the ready availability of hospice and palliative care; Memorial Sloan Kettering Cancer Center does. Experiences in other settings may be very different, Koo acknowledged.
“What is applicable to all is the emphasis on communication and education with patients, families, and members of the hospital staff,” he said.
Regardless of the reason a patient with cancer lands in the hospital, the hospitalization may be a triggering event for the patient who has not fully grasped their cancer prognosis, and the clinical reality is dire.
“Oncology hospitalists face this multiple times a day, and I think we do so because hospitalization is often an inflection point which presents a unique opportunity for patients and families to really hear what they may — or may not — have been told before,” Koo said.
‘My Oncologist Said I’m Doing Better’
Marina George, MD, vice president of inpatient medical operations at The University of Texas MD Anderson Cancer Center in Houston, said she has been “blown away by the variety of things that we do as hospitalists.”
One thing that hospitalists should be doing is inquiring about the goals of care. That goes beyond whether a patient would want to be resuscitated and placed on a ventilator. It entails exploring the patient’s goals, values, wishes, and understanding of their disease.
“If we do not ask what your wishes are, we will inadvertently do the wrong thing,” George said.
Talking with patients might reveal potential sources of misunderstanding about their condition.
If a patient says, “My oncologist said I’m doing better,” what was the context?
That they did not have any side effects during their last chemotherapy treatment could be why they think they are improving, George said.
By considering a patient’s preferences early on, hospitalists might be able to help patients and caregivers spend less time in the hospital if that is what they want.
“If the preference is known earlier, we would tailor treatments and tailor the healthcare journey in a way that would help the person experience life in a very different way,” George said.