Decisions about Limiting Treatment in Cancer Patients: A Systematic Review and Clinical Ethical Analysis of Reported Variables

Background: Survey research indicates that decisions about the provision and limitation of treatment near the end of life in patients with cancer vary considerably. Objectives: The study objectives were to review the evidence on variables associated with explicit decisions about limitation of treatment in patients with cancer and to critically appraise the factors from a clinical ethics perspective. Methods: A search was conducted of studies published in EMBASE, CINAHL, PsycINFO, Assia, Current Contents Medicine, Belit, and Euroethics before February 5, 2014. Eligible studies reported data on explicit treatment limitation in patients with cancer and included a statistical analysis on possibly associated factors. Information on study participants, types of limited treatment, and variables associated with limiting treatment were extracted by two researchers independently. Data synthesis was performed jointly by researchers from oncology, medical ethics, and social sciences. Results: The search yielded 897 publications, of which 7 were relevant for this review. Factors significantly associated with decisions about limitation of treatment could be distinguished in three categories: first, sociodemographic variables such as the ethnic background of patients; second, health- or treatment-related variables including a lack of capacity in patients with cancer; and third, patients' preferences and the role of relatives in decisions about limitation of treatment. Limitations to this study are that the studies lacked a predefined hypothesis and they all had been conducted in Western countries. Conclusion: The identified variables raise ethical issues with regards to possible influence of value judgments underlying decisions about limitation of treatment in end-of-life care.