Original Article

Ethical issues in patients referred for palliative radiation therapy

Divya Yerramilli 1, Gregory Parker 2, Virginia LeBaron 3, Monica Krishnan 1, Lauren Hertan 4,
Alexander Spektor1, Ron Shiloh1, Sonia Skamene5, Tracy Balboni1
1
Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA; 2Department of Radiology, Hospital of
University of Pennsylvania, Philadelphia, PA, USA; 3School of Nursing, University of Virginia, Charlottesville, VA, USA; 4Department of Radiation
Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA; 5Department of Radiation Oncology, McGill University Health Centre
Montreal, Quebec, Canada
Contributions: (I) Conception and design: T Balboni, D Yerramilli; (II) Administrative support: T Balboni; (III) Provision of study materials or
patients: T Balboni, M Krishnan, L Hertan, A Spektor, R Shiloh, S Skamene; (IV) Collection and assembly of data: G Parker, D Yerramilli, T
Balboni; (V) Data analysis and interpretation: D Yerramilli, T Balboni; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All
authors.
Correspondence to: Divya Yerramilli, MD, MBE. Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, 55 Fruit
Street, Lunder LL2, Boston, MA 02114, USA. Email: [email protected].

Background: As patients with advanced cancer approach end of life, ethical issues may arise. We describe
ethical issues encountered by radiation oncologists in this setting.
Methods: A prospective, survey-based study assessed 162 consecutive consults for palliative radiation
therapy (PRT) over 4 months at 3 hospitals. Consulting radiation clinicians completed a survey assessing
palliative care issues encountered, based on national guidelines. Ethical issues included 5 subthemes
(conflict between clinicians, caregiver-clinician conflict, internal conflict, feeling unable to do what was
best for the patient, and violation of personal morals), an option for unclassified issues, and open-ended
responses. Multivariate analyses (MVA) assessed potential patient-related predictors of ethical issues: gender,
performance status (PS), PRT indication, physical symptoms, and presence of psychosocial, goals of care,
care coordination, cultural, or spiritual issues.
Results: Of 162 surveys, 140 were completed (response rate =86%). Overall, 14 (10%) surveys identified
ethical issues relevant to care; 11 of 14 (78%) identified more than 1 ethical issue. Half (7; 50%) involved
conflict between clinicians and clinician-caregiver conflict; 6 (43%) involved clinician distress or internal
conflict; and 2 (14%) felt impeded from doing what they felt was best for the patient. Open-ended responses
revealed differences in opinion between medical specialties (n=6, 43%), and conflict related to coordination
of care among clinicians (n=3, 21%). On UVA, ethical issues were associated with PRT referrals for bleeding,
dyspnea, or dysphagia due to visceral metastases (30%) versus CNS indications such as brain metastases or
cord compression (7%) or for bony metastases (4%) P<0.001. On MVA, ethical issues were associated with
PRT for visceral metastases (OR 13.0; 95% CI, 2.3–74.6; P<0.001) and presence of spiritual issues (OR 4.0;
95% CI, 1.1–14.5; P=0.04).
Conclusions: At least 1 in 10 referrals for PRT involve ethical issues. Further studies are warranted to
assess the ability of radiation oncologists to manage ethical issues.

Keywords: Ethics; palliation; radiation oncology

Submitted Apr 01, 2019. Accepted for publication Jun 17, 2019.
doi: 10.21037/apm.2019.06.02
View this article at: http://dx.doi.org/10.21037/apm.2019.06.02

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019;8(3):231-239 | http://dx.doi.org/10.21037/apm.2019.06.02
232 Yerramilli et al. Ethical issues in PRT

Introduction While the decision to offer treatment itself may be

challenging, there may be additional ethical issues as
In health care, principles of patient autonomy, beneficence,
radiation oncologists consider how to approach PRT for a
non-maleficence, and justice serve as a moral framework for
given patient. Radiation oncologists have to consider the
patient care (1). Ethical dilemmas often arise when there
patient’s goals of care and prognosis in order to provide
are tensions between these four principles, and providers
appropriate, patient-centered treatment recommendations.
must be able to navigate clinical decision-making in
However, it has been demonstrated that physicians typically
these circumstances. The care of oncology patients often
cannot prognosticate accurately at the end of life, limiting
involves various ethical dilemmas, related to the doctor-
their ability to offer the most appropriate palliative
patient relationship, cultural barriers, concepts of hope,
treatment options (8,9). One study demonstrated that
spirituality, special ethical considerations in pediatric
physicians estimate that 27% of patients they treated within
patients, suffering, and end-of-life (2). These patients often
the last 30 days of life died sooner than expected, suggesting
have complex medical issues and various clinical providers,
that even though they believe they are maximizing
which can make patient autonomy very challenging, as it
benefit for patients, the magnitude of that benefit is likely
is not always clear how beneficence can be optimized for
overestimated (10). Furthermore, patients and caregivers do
patients, as symptom-relief and treatment response are not
not necessarily understand the intent of palliative treatment
always predictable (3,4). Many cancer therapies themselves,
clearly, mistaking their treatment as curative, which may
whether palliative or curative in intent, can cause harm or
result in unintended harm (11).
toxicity, making non-maleficence a difficult principle to
To best educate and prepare radiation oncologists to
uphold. Even when patients have clearly decided to favor
manage any ethical issues as they care for patients with
palliative intent of treatment over curative, there can still
advanced cancer, a thorough description of the frequency
be conflicts in treatment plans, between providers, and
and types of ethical issues that are encountered is required.
between family members. A qualitative study of nurses and
However, little data are available to describe the frequency
physicians regarding end-of-life issues in a population of
and range of ethical issues encountered in patients
patients admitted to the ICU showed that uncertainty about
considered for PRT. Our research fills a critical gap in the
the best course of action in patient led to moral distress, and
literature by describing the frequency and types of ethical
competing values, hierarchy, and communication emerged
issues encountered by radiation oncologists caring for
as common themes (5). Given the complexity of care and
patients referred for PRT through a survey-based study.
the acuity of illness in patients with advanced cancer,
providers of these patients are often exposed to ethical
dilemmas. Methods
Radiation oncologists often encounter patients with
Survey and participants
advanced cancer when they are referred for palliative
radiation therapy (PRT). PRT is often delivered in the After receiving approval from the Institutional Review
context of complex, urgent, medical scenarios, since Board of participating radiation oncology centers, we
palliative radiotherapy is generally delivered when delivered surveys electronically to radiation oncology
metastatic disease has progressed and become emergently clinicians who received consultations for PRT through a
symptomatic and potentially life threatening. These specific palliative radiation oncology service at 3 hospitals
emergencies include brain metastases, spinal cord over the course of 4 months. Patients were referred
compression, obstruction from visceral metastases, and either through our inpatient consultation team, generally
bleeding (6). Often, various specialty teams work in parallel comprised of dedicated attending physicians and nurse
to manage these emergencies, and there may not be a clear practitioners who specialize in the care of these patients,
or most obvious choice of optimal first-line treatment. For and rotating residents, for whom this service is embedded
example, the management of brain metastases and spinal throughout their training. They could also be referred
cord compression involve parallel or sequential care with for outpatient evaluation by these same practitioners if
neurosurgery (7), and obstructive masses and bleeding they had a palliative intent treatment but were stable
tumors can involve a variety of other interventional enough to be seen as outpatients, such as pain from a
specialties. bony metastasis. All consultations received between

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Annals of Palliative Medicine, Vol 8, No 3 July 2019 233

May 19, 2014 and September 26, 2014 were eligible for categorical variables. Continuous variables were analyzed
evaluation if the patient was 21 years of age or older, with as a mean and standard deviation or a median and range.
incurable, metastatic cancer. Immediately after each PRT Palliative care issue domains were dichotomized as
consultation, the consulting clinician was sent a survey to “relevant” or “not relevant” to each consultation. We
be completed within 5 business days of the consultation. used univariate (UVA) analyses to initially assess potential
Requests to complete the survey were sent three times over predictors of ethical issues, which included gender, age,
the 5-day interval. We sent 15 clinicians, consisting of nurse marital status, primary cancer type, PS, indication for PRT,
practitioners, resident physicians, and attending physicians, PRT recommendation, and plan for future anticancer
162 surveys over the study period. For their participation, therapy. In addition, we assessed the relationship of ethical
survey respondents received one $25 gift card regardless of issues to other issues identified in the surveys, e.g., the
the number of surveys completed. presence of physical symptoms, psychosocial issues, goals
The survey was developed as part of a comprehensive of care, care-coordination, cultural issues, or spiritual issues
assessment of the burden of palliative care issues using chi square tests. Our multivariable analysis model
encountered in palliative radiation consultations, with the included all significant (P<0.05) univariate predictors to
survey development methods previously described (12). assess relationships to ethical issues. We did not control for
The domains of palliative care assessed were derived from provider-specific variables as there were insufficient events
the National Consensus Project domains of palliative care per provider for meaningful analysis.
and the National Comprehensive Cancer Network (13,14). Open-ended responses were independently reviewed
Eight palliative care domains were evaluated—physical and coded for similar themes (Author 1 and Author 9) and
symptoms, psychosocial issues, cultural consideration, validated by a third person in the case of disagreement
spiritual needs, care coordination, advanced care planning, (Author 4).
goals of care, and ethical and legal issues. Within 1 week
of the consultation, clinicians ranked the relevance of each
Results
of the eight-palliative care domain to that patient’s care
within radiation oncology on a 5-point scale from ‘not Characteristics of the patient consultations are shown in
relevant’ to ‘extremely relevant’. Within each domain, Table 1. Over the course of the study, 162 patients were seen
there were further subdomains (31 in total) to which in consultation for PRT. Of the 162 surveys sent to clinicians,
clinicians indicated the relevance to care as ‘yes’, ‘no’ or 140 responses were completed (86% response rate). Patients
‘not assessed’. Within the ethical issues domain, there were most commonly referred for PRT for pain (n=80, 57%)
were five subdomains of assessment identifying the types brain metastases (41, 29%) cord compression (18, 13%) and
of ethical conflicts encountered, including: (I) conflict visceral metastases (28, 20%). PRT was recommended in
between clinicians, (II) conflict between caregivers and 120 of the 140 consultations (86%).
clinicians, (III) internal conflict, (IV) feeling blocked Of the 140 patient consultations, 14 (10%) involved
from doing what was best for the patient, (V) violation of ethical issues relevant to the patient’s care, with the majority
personal morals, and an option for unclassified issues, with of ethical issues being highly relevant to the radiation
an open-ended response. oncologist’s care of the patient. For 3 out 14 patients,
Patient demographic and disease data were extracted radiation was not recommended, and the remainder
from the electronic medical record corresponding to received PRT. Of those 14, 11 (78%) involved more than
each completed survey. Demographic information one ethical issue relevant to care. Types of ethical issue
collected included age, gender, and marital status. Disease encountered by radiation oncologists are shown in Figure 1,
information collected included primary cancer type, with 7 (50%) of ethical issues involving conflict between
performance status (PS), reasons for radiation therapy clinicians about the care plan for the patent; half involving
consultation, and radiation therapy recommendation and conflict between patient/family and clinicians about the care
target site. plan; (43%) involved clinician distress or internal conflict
within the care for that patient; a small minority (14%) felt
impeded from doing what they felt was best for the patient;
Statistical analysis
and no clinician noted the care plan violated personal ethics
Descriptive statistics were calculated as proportions for or morals. Five patient encounters were noted to have other

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019;8(3):231-239 | http://dx.doi.org/10.21037/apm.2019.06.02
234 Yerramilli et al. Ethical issues in PRT

Table 1 Characteristics of consultations for PRT

Characteristic N=140 [%]

Gender

Male 79 [56]

Female 61 [44]

Age (median, range) 63 [29–89]

Primary cancer

Lung 39 [28]

Prostate 14 [10]

Breast 18 [13]

Melanoma 14 [10]

Other 55 [39]

ECOG performance status (median, range) 1.4 [1]

Reason for palliative radiation consultation

Skeletal indications 85 [61]

Pain 80 [57]

Impending/pathological fracture 5 [4]

Neurologic indications 59 [42]

Brain metastases 41 [29]

Spinal cord compression 18 [13]

Visceral Indications 28 [20]

Dyspnea 14 [10]

Dysphagia 3 [2]

Tumor associated bleeding 11 [8]

Other 8 [6]

Radiation therapy recommended 120 [86]

Plan of care

New metastatic cancer therapy, plan for further cancer-directed therapy 27 [19]

New metastatic cancer therapy, no further cancer-directed therapy 2 [1]

Established diagnosis, continuing cancer-directed therapy 88 [63]

Established diagnosis, no further cancer-directed therapy 23 [16]

Survey respondent clinical role

Nurse practitioner 72 [51]

Resident physician 51 [36]

Attending physician 17 [12]

PRT, palliative radiation therapy.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019;8(3):231-239 | http://dx.doi.org/10.21037/apm.2019.06.02
Annals of Palliative Medicine, Vol 8, No 3 July 2019 235

63% 38%

30%
50%
23%

38% 15%

8%
25%
0%
Visceral metastases Bony metastases CNS metastases
13%
Figure 2 Indications for palliative radiation in consultations
involving an identified ethical conflict.

0%
Conflict or lack of consensus among

Clinician feeling blocked or impeded from doing

clinicians about plan of care

Conflict or lack of consensus among

family/caregivers about plan of care

Personal (clinician) distress or internal

conflict about the plan of care

what is perceived to be best for the patient

Feeling the care plan violates clinician

personal ethics or morals

Other

provider, and 10% (n=1) identified financial concerns as

the source of conflict.
On univariate analysis, ethical conflicts were significantly
(P<0.05) associated with PRT referrals for bleeding,
dyspnea, or dysphagia due to visceral metastases (30%)
versus for CNS indications like brain metastases or cord
compression (7%) or bony metastases (4%) (Figure 2),
P<0.001. Ethical issues tended to be more common
among patients with psychosocial (13% vs. 4%, P=0.13) or
spiritual issues (23% vs. 5%, P=0.001). Gender, PS, PRT
recommendation and proceeding to hospice/end-of-life care
were not significantly associated with the presence of ethical
Figure 1 Types of ethical conflict identified within palliative
issues (Table 2). We also examined the relationships of other
radiotherapy consultations that involved ethical issues (N=14).
palliative care issues relevant to ethical issues (Table 2), with
23% of patients with spiritual issues present associated
with the presence of ethical issues versus 5% of patients
unspecified ethical issues.
without spiritual issues identified associated with ethical
Open-ended responses included a variety of conflicts,
issues present (P<0.001). In other words, if patients were
including disease-related conflict, patient-provider
likely to have spiritual issues present, they were also more
conflict, provider-provider conflict, and financial
likely to have ethical issues. The presence of psychosocial
concerns. Of the 10 open-ended responses, 50% (n=5)
issues demonstrated a trend of association with the presence
identified disease-related conflict, where there were
of ethical issues (13% vs. 4%, P=0.13), although not
difficult management decisions based on the disease
statistically significant.
progression or presentation alone, such as two sites of On multivariate analysis, PRT for visceral metastases
involvement. Examples included a patient presenting (OR 13.0; 95% CI, 2.3–74.6, P<0.001) and presence of
with a new mediastinal tumor in the setting of metastatic spiritual issues (OR 4.0; 95% CI, 1.1–14.5, P=0.04) were
prostate cancer, a patient presenting with brain metastases significantly associated with ethical issues.
as well as an enlarging neck mass; and a new diagnosis of
metastatic versus limited disease that impacted staging
Discussion
and subsequent course of care. Additionally, 30% (n=3)
identified conflict between the patient or family’s wishes Care for patients with advanced cancer can be extremely
and those of their provider, 10% (n=1) identified conflict complex, involving multiple disciplines, medical sub-
between the clinician completing the survey and another specialties, and treatment options. Radiation oncologists

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236 Yerramilli et al. Ethical issues in PRT

Table 2 Relationship of identified ethical issues with patient characteristics and other palliative care issues; and comparison of characteristics
between patients with ethical issues identified and no ethical issues identified
Characteristic Ethical issues identified, N=14 No ethical issues identified, N=126 P value
Gender 0.53
Male 9 (11.4%) 70 (88.6%)
Female 5 (8.2%) 56 (91.8%)
Age (median, range) 59.3 (SD =17.1) 61.7 (SD =12.3) 0.62
ECOG performance status 0.52
PS 0-2 12 (10.3%) 104 (89.7%)
PS 3-4 1 (5.6%) 17 (94.4%)
Reason for palliative radiation consultation 0.0008*
Skeletal indications 2 (3.6%) 53 (96.4%)
Neurologic indications 4 (7.3%) 51 (92.7%)
Visceral indications 8 (30.0%) 19 (70.4%)
Radiation therapy recommendation 0.31
PRT recommended 11 (9.0%) 111 (91.0%)
PRT not recommended 3 (16.7%) 15 (83.3%)
Future plans for anti-cancer therapies 0.27
Plan for further anti-cancer therapy 13 (11.3%) 102 (88.7%)
Proceeding to hospice/end of life care 1 (4.0%) 24 (96.0%)
Presence of other palliative care domains
Physical symptoms 0.65
Present 12 (9.6%) 113 (90.4%)
Absent 2 (13.3%) 13 (86.6%)
Psychosocial issues 0.13
Present 12 (12.6%) 83 (87.4%)
Absent 2 (4.4%) 43 (95.6%)
Cultural considerations 0.94
Present 2 (10.5%) 17 (89.5%)
Absent 12 (9.9%) 109 (90.1%)
Spiritual needs 0.0014*
Present 9 (23.1%) 30 (76.9%)
Absent 5 (5.0%) 96 (95.0%)
Care coordination 0.25
Present 14 (10.9%) 115 (89.1%)
Absent 0 (0%) 11 (100%)
Advanced care planning 0.45
Present 5 (13.1%) 33 (86.8%)
Absent 9 (8.8%) 93 (91.2%)
Goals of care 0.23
Present 14 (10.9%) 114 (89.1%)
Absent 0 (0%) 12 (100%)
*, significant at P<0.05. PRT, palliative radiation therapy.

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Annals of Palliative Medicine, Vol 8, No 3 July 2019 237

commonly encounter these patients through consultations and coordinated visits for patients referred for palliative
for PRT, which are estimated to comprise at least a third of indications on the impact of ethical issues.
treatments administered by radiation therapy (15). Of these Strengths of this study include the prospective
patients, our study finds that approximately 1 in 10 referrals identification of ethical conflicts in a population of patients
for PRT involve ethical issues relevant to the radiation referred for PRT. Other studies examining ethical conflict
oncologist’s care of the patient. in oncology populations generally identify patients who
Ethical issues may be identified at a higher frequency have already been referred for ethical consultation (2,19-21),
in consultations for palliative radiation in patients who which is often an underutilized service, and may represent
are referred for bleeding, dysphagia, and dyspnea versus a highly selective population. Therefore, this study can give
those who are referred for cord compression, brain us a greater scope of the range and types of ethical conflicts
metastases, and pain. Given that clinician-clinician conflict radiation oncologists can expect to encounter. Furthermore,
was identified in this context, one possible hypothesis for the open-ended responses provide insight into potential
this observation is the management of the former end-of- opportunities for further research, intervention, and
life issues often involves many potential consultants and education. While we captured ethical issues that arise in
management options, while the latter conditions of cord a palliative setting, there can be many ethical issues and
compression, brain metastases, and pain typically involve situations fraught with moral distress arising in curative
one surgical subspecialty and radiation oncology alone as settings, which may be even more difficult to identify. We
primary management. This may suggest development of hope that education in medical ethics will allow providers
care pathways and further research on the comparative to identify these issues throughout the course of a patient’s
effects of interventions for visceral metastases may be care, regardless of treatment intent.
helpful. Future research may better define the clinical Limitations of this study are that these responses were
threshold for radiation therapy for bleeding metastases after elicited from providers, and not patients. It is possible
endoscopic approaches. that patients may identify a greater proportion and range
Furthermore, our study demonstrates that ethical issues of ethical conflicts than were observed and discussed
may be identified more readily when there are spiritual within the consultation. Furthermore, this study asked
concerns. Literature on ethical dilemmas often report radiation oncology clinicians about the presence of
conflict in the setting of religious or spiritual beliefs, and ethical issues relevant to care of the patients receiving
our findings support this (16). Spiritual distress, while PRT. Though most appropriate to inform the scope
a patient-specific characteristic, was identified by our of ethical issues encountered in radiation oncology
providers as relevant to the consultation, and therefore may care, this likely underestimates the full scope of ethical
track with the provider’s ability to identify ethical issues. issues experienced in the care of patients with advanced
For example, patients who vocalize spiritual concerns, cancer. Further studies, which incorporate surveys of all
whether it is an existential dilemma at the end of life or clinical providers, patients, and family members, may
they feel aspects of their care conflict with their religious enrich the data regarding ethical conflicts and provide
framework, may be more obviously identified by providers additional points for intervention and improvement.
as having an ethical conflict, instead of those patients who While some may raise concern that the majority of the
have coordination of care issues alone. From prior studies, conflicts were identified by nurse practitioners or by
we know providers may lack comfort in discussing spiritual residents, we believe that ethical issues can be identified
concerns and this may also account for some ethical conflict by any member of a clinical team, by patients, or family
(17,18). Incorporating training in engaging with patients’ members. There is no specific reason why attending
spirituality may help lessen the impact of this on ethical physicians would be better suited to identifying ethical
conflict. issues than any other member of the team. In fact, one
The subjective responses recorded provide interesting may argue that recent changes in curriculum better train
insights into the types of situations leading to ethical young trainees in the identification of ethical issues
conflict, with themes suggesting that disagreement about (22,23). Further studies that investigate the level of
the plan of care between various specialties is an important medical training and identification of ethical issues in
source of moral distress. Future studies may involve these settings may be illustrative as to whether or not
examining the role of multidisciplinary review, discussion, the rank or role of the provider has any bearing on these

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238 Yerramilli et al. Ethical issues in PRT

findings. Additionally, the rate of ethical burdens may not 7. Patchell RA. The management of brain metastases. Cancer
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Conflicts of Interest: The authors have no conflicts of interest Clinical Guidelines for Quality Palliative Care. 2013.
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Clinical Practice Guidelines in Oncology: Palliative Care
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Cite this article as: Yerramilli D, Parker G, LeBaron V,

Krishnan M, Hertan L, Spektor A, Shiloh R, Skamene S,
Balboni T. Ethical issues in patients referred for palliative
radiation therapy. Ann Palliat Med 2019;8(3):231-239. doi:
10.21037/apm.2019.06.02

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019;8(3):231-239 | http://dx.doi.org/10.21037/apm.2019.06.02