symposium article Annals of Oncology 23 (Supplement 7): vii55–vii58, 2013

doi:10.1093/annonc/mdt262

Ethical issues in the geriatric patient with advanced

cancer ‘living to the end’
M. Daher*
Professor of Surgery, and Director of Medical Ethics, University of Balamand, Beirut, Lebanon

Cancer incidence will increase as the population ages; there will be a 50% increase in new cancer cases over the next 20
years, and the biggest rates of increase will occur in the developing world. Owing to technical advances in the care of
critical illness, as it is the case in elderly people with advanced cancer, physicians, patients and families are often
confronted with ambiguous circumstances in which medical advances may inadvertently prolong suffering and the dying
process rather than bring healing and recovery.
In this review of the ethical issues confronting physicians who care for patients with advanced life-limiting illnesses like
cancer, a philosophical debate continues in the medical community regarding the rightness or wrongness of certain
actions (e.g. physician-assisted death, euthanasia), while at the same time there is a strong desire to find a common
ground for moral discourse that could guide medical decision-making in this difficult period in the lives of our patients. We
will discuss how a good palliative care can be an alternative to these ethical dilemmas.
Although some issues (e.g. the role of physician-assisted death in addressing suffering) remain very controversial, there
is much common ground based on the application of the four major principles of medical ethics, no malfeasance,
beneficence, autonomy and justice.
Thus, the physician’s primary commitment must always be the patient’s welfare and best interests, whether the physician

symposium
is treating illness or helping patients to cope with illness, disability and death. A key skill here is the communication of bad

article
news and to negotiate a treatment plan that is acceptable to the patient, the family and the healthcare team.
Attention to psychosocial issues demands involvement of the patients and their families as partners. Physicians should be
sensitive to the range of psychosocial distress and social disruption common to dying patients and their families. Spiritual
issues often come to the fore. An interdisciplinary healthcare team can help in these areas.
The goals of this review are to raise the awareness of doctors, nurses and other members of the healthcare team to the
important ethical issues that must be addressed in providing medical care to elderly patients with advanced cancer; and
also to encourage members of the healthcare team to take the ethical issues seriously so that we can improve the
circumstances of a vulnerable group of patients—the elderly patients with cancer.

introduction circumstances in which medical advances may inadvertently

prolong suffering and the dying process rather than bring
In almost every country, the proportion of people aged over 60 healing and recovery [1].
years is growing faster than any other age group, as a result of In this review of the ethical issues confronting physicians who
both longer life expectancy and declining fertility rates. Cancer care for patients with advanced life-limiting illnesses like cancer,
incidence will increase as the population ages; there will be a a philosophical debate continues in the medical community
50% increase in new cancer cases over the next 20 years, and the regarding the rightness or wrongness of certain actions (e.g.
biggest rates of increase will occur in the developing world physician-assisted death, euthanasia), while at the same time
(Globocan, 2008). there is a strong desire to find a common ground for moral
In Lebanon, there are currently around 8250 new cases of discourse that could guide medical decision making in this
cancer diagnosed each year; around 40% of those occur in difficult period in the lives of our patients.
persons ≥65 years representing 3300 cases (Lebanese National We will discuss how a good palliative care can be an
Cancer Registry) alternative to these ethical dilemmas.
Owing to technical advances in the care of critical illness, as it
is the case in elderly people with advanced cancer, physicians,
patients, and families are often confronted with ambiguous ethical principles in end-of-life care
Ethics is a branch of philosophy that examines rights and
wrongs, what should or ought to be done. Clinical ethics refer to
*Correspondence to: Dr M. Daher, Saint George Hospital- UMC,
POBox 166378-Achrafieh, Beirut, Lebanon. Tel: +961-1-581714; Fax: +961-1-582560; application of the science and understanding of morality in the
E-mail: [email protected] field of medicine and health sciences. They are defined as ‘the

© The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email: [email protected].
symposium article Annals of Oncology

obligations of moral nature, which govern the practice of made decisions for patients according to their professional
medicine.’ The goal of clinical ethics is to improve the quality of values, to a more equal relationship of shared decision making,
patient care, emphasizing the commitment to the well-being of in which physicians provide information that allows competent
patients [2]. adult patients to make their own choices, referred to as
Several ethical issues arise in the care of elderly patients with ‘informed consent.’ Autonomy is founded in the overall desire
advanced cancer. Although some issues (e.g. the role of of most human beings to control their own destiny, to have
physician-assisted death in addressing suffering) remain very choices in life, and the right to consent to or refuse treatment
controversial, there is much common ground based for the [7]. Although the physician has an obligation to respect the
application of the Hippocratic Oath that embraced the classical patient’s wishes, he or she also has a duty to fully inform the
principles of medical ethics of beneficence, non-malfeasance, patient of the probable consequences of those wishes. Justice is
confidentiality, autonomy, and justice. Thus, the physician’s often regarded as being synonymous with fairness; in a general
primary commitment must always be to the patient’s welfare sense, people are treated justly when they receive what they
and best interests, whether the physician is treating illness or deserve (Table 1). The pledge promises to respect the patient’s
helping patients to cope with illness, disability, and death [3]. rights and to place his welfare above all else (Table 2).
The goal of palliative care is to relieve suffering. Suffering has A key skill in this situation is the communication of bad news;
been defined as ‘the state of severe distress associated with and then to negotiate a treatment plan that is acceptable to the
events that threaten the intactness of the person [4 ].’ The patient, the family, and the healthcare team. The patient and his
World Health Organization has defined palliative care as ‘the or her family should be able to discuss in advance their desires
active total care of patients whose disease is not responsive to regarding life-sustaining treatments and personal care.
curative treatment. Control of pain, of other symptoms, and of Physicians should facilitate this advance care planning, and
psychological, social, and spiritual problems, is paramount. The must support the dignity of all persons and respect their
goal of palliative care is achievement of the best quality of life uniqueness [8].
for patients and their families [5 ]’.
Healing and alleviation of suffering, the classical duties of
physicians, have been practiced throughout the history of the
human society development. The patient–physician relationship advanced directives and informed
is a time-honored tradition and a reward for the compassionate consent
physician and the appreciative patient. The first code of ethics
between the physician and the patient appeared in 1750 BC, With progression of an advanced illness like advanced cancer,
when Hammurabi was commissioned in Babylon to establish there is increasing debility and loss of independent function that
laws that govern the practice of medicine [6]. erodes a patient’s autonomy. This progressive loss of autonomy,
Different perceptions of a patient’s suffering within the in as much as it further threatens the integrity of the person,
medical team (e.g. between nurses and physicians), between the adds to the suffering of these patients.
medical team and family members, or within families can lead That is why the practical extension of patient autonomy has
to conflict and are not infrequent reasons for ethics been the development and use of advanced directives. Typically,
consultations in patients with advanced life-threatening advanced directives can be in the form of a living will in which
illnesses. treatment preferences usually related to care at or near the end
This will provide the context for the application of the major of life (especially regarding attempts at resuscitation) are
principles in the Hippocratic Oath. Beneficence is the obligation documented, or a durable power of attorney for healthcare, in
of healthcare providers to help people in need (relieve their which a surrogate decision maker is identified (often one’s
suffering). Non-malfeasance is the duty of healthcare providers spouse or other close relative) [9, 10].
to not harm their patients (exacerbate their suffering). Doing In actual practice, it is almost impossible to anticipate every
good (beneficence) and doing no harm (no malfeasance) are possible situation that might arise, especially during intensive
two complementary ethical principles that impose affirmative care of a critically ill individual, in which specific decisions can
duties to maximize benefits and minimize risks to the patients. be made in advance. Thus, the principle of autonomy as applied
Autonomy is the right of a person to choose and follow his or to medical decision making in the context of patient
her own plan of life and action. In recent decades, the
relationship between patients and physicians has been evolving
from one characterized by paternalism, in which physicians Table 2. Patients’ rights

Table 1. Ethics and end-of-life care—major principles (i) Right for a good quality care
(ii) Right for a free choice
(iii) Right for healthcare decision
(i) Nonmaleficence ‘first do no harm’ (iv) Right for clear information
(ii) Beneficence—a duty to do good (not just avoid harm) (v) Right for confidentiality
(iii) Autonomy—the recognition of the right of self-determination, (vi) Right for information and health education
establishing one’s own goals of care (vii) Right for human dignity
(iv) Justice—the equitable distribution of often limited healthcare resources. (viii) Right for spiritual assistance

vii | Daher Volume 23 | Supplement 7 | October 2013

Annals of Oncology symposium article
incapacitation is in a process of evolution depending on the (iv) Legalization of physician-assisted death would be unsafe in
country and culture [2,7,11]. communities like ours in the Middle- East. Patients with
The under-treatment of pain and other symptoms is well limited or unequal access to healthcare (e.g. the poor)
documented; the causes are complicated and not well would be particularly vulnerable, as physician-assisted
understood. Although, an improvement in pain control is noted death would inherently be quite ‘cost effective [19 ].’
these last few years, due to a better health professionals education, (v) Physician-assisted death poses an inherent conflict of
more public awareness and adaptation of health policies to the interest for physicians. With rising healthcare costs
international recommendations. Guidelines have been also ( particularly at the end of life), the pressure for more ‘cost
developed to assist physicians in controlling other symptoms, effective’ solutions (e.g. physician-assisted death) will
such as nausea, vomiting, fatigue, and breathlessness [12, 13]. mount. Physician-assisted death is in direct conflict with
the Hippocratic Oath and tradition. And in most countries
in the Middle-East where people are believers and have
faith, such a solution goes against the religious
withholding/withdrawing therapies vs. recommendations.
physician-assisted death (vi) Although physicians may be able to address the physical
There is no fundamental difference ethically between distress of the dying, they may not have the skills or
withdrawing or stopping a treatment that is no longer resources to address deeper, existential issues troubling
beneficial, and not starting or withholding such a their patients. This lack of knowledge does not justify
treatment [14]. taking a patient’s life when others who may have the skills
Once a decision is made to withhold a ‘life-sustaining’ and patience are available to help.
treatment, other ongoing treatment should be reviewed as to the (vii) Palliative care team has here its primary role and place.
appropriateness of its continuation, as well. The decision to
withdraw life-sustaining therapy is rarely an emergency. It is
essential to take all the time necessary to resolve any conflicts
that may exist between the medical staff and family members or conclusions
that may exist within the medical team [15].
Patients and their physicians together face a number of
Clinicians should be aware that personal beliefs and values
challenging ethical issues at the end of life of an elderly patient
often play a dominant role in their clinical decisions. All team
with advanced cancer. Although some issues (e.g. the role of
members (attending physician, residents, nurses, social workers,
physician-assisted death in addressing suffering) remain very
etc.) who have a direct role in the patient’s care should have
controversial, there is much common ground based on the
input in the process [16].
application of the four major principles of medical ethics, non-
Thus, withholding or withdrawing treatments that are no
malfeasance, beneficence, autonomy, and justice.
longer beneficial or administering opioids for pain relief that
Thus, the physician’s primary commitment must always be
may indirectly hasten death are not euthanasia. In the ongoing
the patient’s welfare and best interests, whether the physician is
debate regarding physician-assisted death (euthanasia or
treating illness or helping patients to cope with illness, disability,
physician-assisted suicide), the most important argument in
and death.
favor of the practice relates to suffering. If suffering is the
The physician must support the dignity of all persons and
greatest evil (which many advocates of physician-assisted death
respect their uniqueness. A key skill here is the communication
would endorse), then all means should be available to manage
of bad news and to negotiate a treatment plan that is acceptable
it, including intentionally causing the premature death of one’s
to the patient, the family, and the healthcare team.
patients [17].
Attention to psychosocial issues demands involvement of the
There are a number of reasons to resist embracing such a
patients and their families as partners. Physicians should be
‘solution’ to the suffering of our patients [18]:
sensitive to the range of psychosocial distress and social
(i) Requests for physician-assisted death are often a sign of disruption common to dying patients and their families.
unaddressed issues, including inadequately treated physical Spiritual issues often come to the fore. An interdisciplinary
symptoms (e.g. pain), untreated clinical depression, fear of healthcare team can help in these areas.
a loss of control (autonomy), fear of being a burden, and The goals of this review are to raise the awareness of doctors,
potential existential or spiritual distress. nurses, and other members of the healthcare team to the
(ii) Physical suffering can be relieved without prescribing a important ethical issues that must be addressed in providing
lethal drug. Distressing symptoms can be controlled in medical care to elderly patients with advanced cancer. And also
>95% of cases with medications, supportive, and palliative to encourage members of the healthcare team to take the ethical
care. Terminal or palliative sedation can be used to control issues seriously so that we can improve the circumstances of a
very difficult symptoms without taking a life. vulnerable group of patients—the elderly patients with cancer.
(iii) The end of life is a critical time for personal growth.
During the last days and weeks of life, a number of very
important activities can occur including reconciliation and
healing of relationships, life review, and spiritual growth as
disclosure
one searche for meaning in one’s suffering. The author has declared no conflicts of interest.

Volume 23 | Supplement 7 | October 2013 doi:10.1093/annonc/mdt262 | vii

symposium article Annals of Oncology

references 10. Daher M. Ethical issues in end-of-life care. J Pediatr Hematol Oncol 2010; 32(1):
41–43. www.jpho-online.com
1. Curtis JR, Rubenfeld GD (eds). Managing Death in the Intensive Care Unit. 11. Daher M. Editorial; gaps in end-of-life care. Lebanese MedJ 2011; 59(1):
New York, NY: Oxford University Press 2001. P37–P39.
2. Randall F, Downie RS. Palliative Care Ethics: A Companion for all Specialties, 2nd 12. Daher M. Challenges and barriers for pain management in cancer Patients. J
edition. Oxford, UK: Oxford University Press 1999. Pediatr Hematol Oncol 2010; 32(5): P425–P428.
3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. New York: Oxford 13. Daher M. Pain relief is a human right. Asian Pacific J Cancer Prev 2010; 11
University Press 1994. (MECC Supplement): 91–95.
4. Cassel EJ. The nature of suffering and the goals of medicine. NEJM 1982; 306: 14. Mularski RA, Osborne ML. The changing ethics of death in the ICU, chapter 2 in
639–645. managing death in the intensive care unit. In: Curtis JR, Rubenfeld GD (eds),
5. World Health Organization. Cancer Pain Relief and Palliative Care: Report of a WHO New York, NY: Oxford University Press 2001; 7–17.
Expert Committee. Geneva, Switzerland: World Health Organization 1990; 11. 15. Pawlik TM, Curley SA. Ethical issues in surgical palliative care: am I killing the
6. Breasted JH. Ancient Time or a History of the Early World: An Introduction to the patient by ‘Letting Him Go’? Surg Clin N Am 2005; 85: 273–286.
Study of Ancient History and the Career of Early Man. Whitefish, MT: Kessinger 16. Hinshaw DB, Pawlik T, Mosenthal AC et al. When do we stop, and how do we do
Publishing 2003. it? Medical futility and withdrawal of care. J Am Coll Surg 2003; 196: 621–651.
7. Danis M, Mutran E, Garrett JM et al. A prospective study of the impact of patients 17. Sulmasy DP, Pellegrino ED. The rule of double effect: clearing up the double talk.
preferences on life-sustaining treatment and hospital cost. Crit Care Med 1996; Arch Intern Med 1999; 159: 545–550.
24: 1811–1817. 18. Kollef MH. Outcome of prediction in the ICU, Chapter 5 in managing death in the
8. Surbone A. Telling the truth to patients with cancer: what is the truth? Lancet intensive care unit. In Curtis JR, Rubenfeld GD (eds). New York, NY: Oxford
Oncol 2006; 7: 944–950. University Press 2001; 39–57.
9. George H. Gallup International Institute, Spiritual Beliefs and the Dying Process. A 19. Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD et al. Clinical problems
Report of a National Survey Conducted for the Nathan Cummings Foundation and with the performance of euthanasia and physician-assisted suicide in the
Fetzer Institute, October 1997;47. Netherlands. N Engl J Med 2000; 342: 551–563.

vii | Daher Volume 23 | Supplement 7 | October 2013