Introduction
In the United States and globally, many individuals are facing or will face a serious illness that requires management of symptoms, pain, and potentially transitions to end-of-life care such as hospice for whom it is an appropriate treatment choice (Morrison & Meier, Reference Morrison and Meier2004). One way to address and help reduce the severity of symptoms and improvement of care among individuals with serious illness is to receive palliative care (National Palliative Care Research Center, 2013), yet most patients with serious illness do not receive palliative care until the final days of life (Cheng et al., Reference Cheng, Willey and Palmer2005). One reason for this underutilization of palliative care might be the stigma surrounding palliative care as something that represents “giving up on the fight.”
Ideally, palliative care is given at the diagnosis of a serious illness and used throughout the trajectory of illness to improve quality of life (Zimmermann et al., Reference Zimmermann, Swami, Krzyzanowska, Leighl, Rydall, Rodin, Tannock and Hannon2016). This early integration of palliative care for those facing serious illness is advocated by the World Health Organization (2008) and has been shown to be critical to symptom management (Higginson et al., Reference Higginson, Finlay and Goodwin2002). Despite the effectiveness of palliative care (Hui et al., Reference Hui, Elsayem and De La Cruz2010), many patients facing a serious illness do not receive palliative care until the final days of life (Cheng et al., Reference Cheng, Willey and Palmer2005). Because late integration of palliative care limits the effectiveness of palliation (Cheng et al., Reference Cheng, Willey and Palmer2005; Morita et al., Reference Morita, Akechi and Ikenaga2005; Osta et al., Reference Osta, Palmer and Paraskevopoulos2008), it is critical to focus on identifying and removing barriers to utilization of palliative care.
Palliative care stigma: A social psychological framework
One potential, yet heavily understudied, barrier to utilization of palliative care is the stigma thought to be associated with using palliative care. A stigmatized individual is someone who possesses an identity that is culturally devalued because of the perceived negative attributes (e.g. stereotypes) or failings of its members (Ablon, Reference Ablon2002; Crocker, Major, & Steele, Reference Crocker, Major, Steele, Gilbert, Fiske and Lindzey1998; Goffman, Reference Goffman2009; Heatherton et al., Reference Heatherton, Kleck and Hebl2003; Major & O'Brien, Reference Major and O'Brien2005; Onyeka, Reference Onyeka2010). Many health-related stigmas exist, including stigma surrounding cancer (Holland, Kelly, & Weinberger, Reference Holland, Kelly and Weinberger2010), mental health (Golberstein, Eisenberg, & Gollust, Reference Golberstein, Eisenberg and Gollust2008), and HIV/AIDS (Chesney & Smith, Reference Chesney and Smith1999). Similar to these health-related stigmas (Goffman, Reference Goffman2009; Hamann et al.. Reference Hamann, Ostroff and Marks2014), stigma surrounding palliative care users is also likely to exist.
Palliative care stigma is thought to be driven by palliative care's negative association with death and dying (Smith et al., Reference Smith, Temin and Alesi2012), which is a heavily stigmatized concept in Western culture (Aries, Reference Aries1981). Currently, Western medicine focuses nearly exclusively on curing illness (e.g., “fight against cancer”) and prolonging life, rather than focusing on improving the quality of life and reducing suffering (Field & Cassel, Reference Field and Cassel1997; Morrison & Meier, Reference Morrison and Meier2004). This false dichotomy of beliefs that treatment is either curative or palliative may contribute to perceptions that palliative care is care exclusively for those who are dying or “giving up.” Although palliative care is designed to aid anyone facing a serious illness with symptom and pain management as well as end-of-life transitions when appropriate (National Palliative Care Research Center, 2013), it is often not viewed in that manner. The stigma surrounding the use of palliative care is likely to prevent some individuals from choosing to use this form of care.
There is preliminary qualitative evidence that palliative care usage is stigmatized. Among individuals receiving palliative care, patients and physicians who transition to palliative care often experience feelings of guilt and shame for “quitting” (Reisfield & Wilson, Reference Reisfield and Wilson2004) as well as devaluation and fear of abandonment or loss of care from others (Friedrichsen, Strang, & Carlsson, Reference Friedrichsen, Strang and Carlsson2002). A recent qualitative study demonstrated that a group of advanced cancer patients and their caregivers perceived (at least initially) palliative care as being associated with death, hopelessness, dependency, and end-of-life care (Zimmermann et al., Reference Zimmermann, Swami, Krzyzanowska, Leighl, Rydall, Rodin, Tannock and Hannon2016). This perception may be due in part to martial metaphors, such as the “war on cancer,” which is frequently used in some forms of care for serious illness (Reisfield & Wilson, Reference Reisfield and Wilson2004). Given this rhetoric, individuals may label those who use palliative care as being individuals who are “giving up” or “losing the battle.”
Although prior qualitative findings suggest it is likely that individuals who choose palliative care are negatively stereotyped as “giving up” or being “quitters,” no quantitative data have yet confirmed the presence of stigma toward palliative care. There is a lack of evidence that an individual's decision to use palliative care may be viewed negatively. To address these prior limitations and build off preexisting research, the present studies aimed to examine stigma toward palliative care quantitatively.
Study 1 sought to provide initial experimental evidence that palliative care usage is stigmatized. We hypothesized that reading about a terminally ill patient who chose palliative care would lead to higher levels of negative stereotyping, more negative perceptions about the patient's treatment choice, and a perception that the patient was less afraid of death than reading about a patient who chose chemotherapy. These two treatment options were chosen to examine attitudes toward individuals choosing a treatment option amongst the two commonly presented treatment options in medical care settings of palliative or curative. Study 2 examined the hypothesis that palliative care stigma is associated with a decreased willingness to use palliative care. The stigma associated with palliative care may also prevent individuals from wanting to use palliative care themselves or enroll family members. The mechanism driving less utilization might be perceived negative stereotypes about palliative care, which was tested as a potential mediator between stigma and willingness to use palliative care in study 2.
Understanding both the possible existence of palliative care stigma and the potential role that stereotypes about those receiving palliative care play in mediating the relationship between palliative care stigma and prospective use of palliative care could provide insight in to how to target this stigma and increase palliative care utilization.
Study 1
In this experiment, participants first read a scenario in which an oncologist described both palliative care and chemotherapy as different treatment options to an advanced cancer patient. These two treatment options were chosen to examine attitudes toward individuals choosing a treatment option amongst the two commonly presented treatment options in medical care settings of palliative or curative care. It is acknowledged that these may not accurately reflect the potential third option of receiving both treatments; however, the goal of the present study was to examine whether stereotypes exist in examining those who choose palliative care versus those who choose curative treatments. Individuals were purposively randomly assigned to one condition or the other, rather than using a within subjects design, to determine if simply reading that a patient chose palliative or chemotherapy influenced their perceptions about that individual.
As noted previously, after reading the scenario, individuals were then randomly assigned to either a palliative care condition (patient chose to use palliative care) or the chemotherapy condition (patient chose to use chemotherapy). After reading the scenario, participants’ attitudes toward the patient in the scenario were assessed. These measures included negative stereotypes about the individual, negative perceptions about the patient's treatment choice, and the perception that the patient was not afraid of death. It was predicted that reading about a scenario in which a patient chose palliative care would lead to more negative stereotypes about the patient and negative perceptions about the patient's treatment choice as well as viewing the patient as being less afraid of death relative to reading about a scenario in which the patient chose chemotherapy. This hypothesis was grounded in prior research indicating that there is stigma associated with patients with advanced illness choosing palliative care treatment over what is perceived as curative treatment (e.g., chemotherapy) as well as a stronger association with death and dying (Zimmermann et al., Reference Zimmermann, Swami, Krzyzanowska, Leighl, Rydall, Rodin, Tannock and Hannon2016).
Methods
Participants
A total of 152 participants were recruited through TurkPrime (Litman, Robinson, & Abberbock, Reference Litman, Robinson and Abberbock2017) in exchange for $0.75 (age: M = 34.43, SD = 11.45). Participants had the following demographics: race/ethnicity: 4.6% Latino, 81.0% white, 7.2% black or African American; 6.5% Asian, 2.0% multiracial, 1.4%, other; sex: 49.7% female; sexuality: 85.6% heterosexual; household income: Mode = $50,001–100,000 (range, <$10,000–$150,000+). Participants were randomly assigned to the palliative care condition (n = 86) or the chemotherapy condition (n = 67).
Procedure
Participants read an oncologist describe two treatment options to a terminally ill, advanced cancer patient: (1) palliative care and (2) chemotherapy (see Appendix). Participants were then randomly assigned to read that the patient chose palliative care (n = 86) or chemotherapy (n = 67). Then participants then completed the following measures.
Measures
All measures included response options that were on a Likert scale anchored at 1 = strongly disagree to 7 = strongly agree.
Negative stereotypes
Eight items measured the extent to which participants negatively or positively stereotyped patients in the scenario. All positive stereotypes were reverse coded to create a total negative stereotype measure, consisting of eight items. Participants were asked to indicate their level of agreement that the following words/phrases describe the patient they read about in the scenario: negative: “lazy,” “quitter,” “closed-minded,” “hopeless,” “weak willed,” and “depressed;” and positive—“giving” and “brave” (α = .82, M = 2.84, SD = 1.02; range: 1.00–5.71).
Treatment decision
Three items measured the extent to which participants held negative attitudes toward the patient's treatment decision. Participants were asked to indicate the degree to which they agreed with the following: “I feel the patient is making the right decision” (reverse coded); “I think the patient should seek a second opinion;” and “I think the patient should explore other treatment options.” The first item was reversed scored so that the total scale assessed the degree to which participants held negative attitudes toward the patient's treatment decision (α = .73, M = 4.14, SD = 1.25; range: 1.00–7.00).
Fear of death
Participants were asked to indicate the degree to which they agreed the patient was “Not afraid of death.” This item was used to judgments about choosing palliative care as being associated with less fear of death and dying.
Results
Participants in the palliative care condition held endorsed significantly higher levels of negative stereotypes (e.g., quitter, lazy, hopeless, weak-willed) (M = 3.05, SD = 1.09) than those in the chemotherapy condition (M = 2.58, SD = 0.87; t(151) = 2.94, p = 0.004) (Figure 1). Participants in the palliative care condition also viewed the patient's treatment decision more negatively (M = 4.33, SD = 1.30) than the chemotherapy treatment decision (M = 3.90, SD = 1.14; t(151) = 2.15, p = 0.033) (Figure 2). Finally, participants in the palliative care condition rated the patient as being significantly more “not afraid of death” (M = 4.93, SD = 1.36) than those in the chemotherapy condition (M = 3.27, SD = 1.32, t(144) = 7.41, p < 0.001) (Figure 3).
Fig. 1. Negative stereotype endorsement by decision condition (study 1). Error bars represent ± 1 standard error.
Fig. 2. Perception of treatment decision by decision condition (study 1). Error bars represent ± 1 standard error.
Fig. 3. Perception of patient as “not afraid of death” by decision condition (study 1). Error bars represent ± 1 standard error.
Results indicate that a terminally ill person choosing palliative care is likely to be negatively stereotyped and derogated for his or her choice. Moreover, this person is more likely to be viewed as not afraid of death, indicating palliative care may be associated as being for those who are nearing death or dying. These finding highlights the existence of palliative care stigma by providing the first experimental evidence that individuals who use palliative care are stigmatized simply for their choice.
Study 2
Study 2 aimed to build off of and illuminate the findings from study 1. Namely, study 2 was designed to examine the possible role of stereotypes in mediating the relationship between perceived palliative care stigma and prospective use of palliative care. The goals of study 2 were twofold: (1) examine if perceived palliative care stigma is associated with less prospective use of palliative care and (2) if negative stereotypes, such as those observed in study 1 (e.g., “quitter,” “hopeless), mediate this relationship.”
We theorized that the more palliative care stigma an individual perceives, the less likely they will be to report a willingness to use palliative care if they or a family member are dying and if an alternative, curative treatment is thought to be available. Based on the results from study 1, we also suggest that one reason palliative care stigma influences prospective usage is because of the negative stereotypes associated with those who use palliative care.
We tested the theoretical model that negative stereotypes about individuals receiving palliative care mediated the relationship between perceived palliative care stigma and prospective use. To test our model, we examined the same negative stereotypes which were examined in study 1 (lazy, quitter, closed-minded, hopeless, weak-willed, depressed) about individuals receiving palliative care as a mediator of palliative care stigma (e.g., giving up fighting one's disease, prevents curative treatment) and prospective use of palliative care for one's self or for one's family member.
We hypothesized that stereotypes would mediate the relationship between palliative care stigma and prospective use of palliative care. Namely, palliative care would predict a refusal of and lack of utilization of palliative care through negative stereotypes. Testing this model will allow better understanding the relationship between palliative care stigma and prospective use as well as highlight potential targets for interventions designed to improve palliative care utilization (e.g., stereotypes about recipients).
Methods
Participants
Participants were 235 individuals recruited through an undergraduate research participant pool in exchange for course credit. After removing individuals who failed attention checks and engaged in random clicking, 199 participants remained (race/ethnicity: 37.9% Latino, 25.1% white, 11.3% multiracial, 8.7% Asian, 6.2% African American, 10.7%, other; sex: 87.4% female; sexuality: 92% heterosexual; household income: Mo = $20,000, range = <$10,000–90,000). (Age was omitted by accident from the survey; however, based on previous research and the prescreen survey, the same quarter of sample makeup is likely to be similar (prescreen age: M = 22.21, SD = 4.05.)
Procedure
Participants were recruited to take part in a study titled, “Healthcare Beliefs Survey.” Participants were asked to complete basic demographic information followed by a measures of perceived palliative stigma, stereotypes (negative and positive) about individuals who use palliative care, and prospective use of palliative care. Participants were then thanked for their time and awarded credit for their course research requirement.
Measures
All measures included response options that were on a Likert scale anchored at 1 = strongly disagree to 7 = strongly agree unless otherwise noted.
Perceived palliative care stigma
Four items measured the extent to which participants perceived palliative care use negatively; e.g. “I believe receiving palliative care represents giving up on fighting one's disease;” “I believe individuals who allow their loved ones to receive palliative care are bad spouses/sons/daughters/mothers/fathers;” “I believe receiving palliative care prevents you from receiving curative treatment (e.g., chemotherapy);” and “I believe individuals who allow their loved ones to receive palliative care are caring for their ill family member” (reverse coded); (α = .73, M = 2.33, SD = 1.08; range: 1.00– 5.50).
Negative stereotypes
The same measure of negative stereotyping from study 1 was used (α = .80, M = 2.63, SD = .91; range: 1.00–6.25).
Prospective use of palliative care
Four separate items were used to examine prospective palliative care use. These items were examined individually within our model as they examine conceptually distinct responses. All questions were asked on the following Likert scale: 1 = very unlikely to 7 = very likely. “How likely would you be to use palliative care if you were dying?” (use if dying; M = 5.60, SD = 1.48; range: 1.00–7.00); “How likely would you be to enroll your family member in palliative care if they were dying?” (enroll family member if dying; M = 5.47, SD = 1.47; range: 1.00–7.00); “How likely would you be to refuse palliative care and choose a curative treatment if there was limited chance the treatment would cure you?” (refuse treatment for self; M = 4.24, SD = 1.65; range: 1.00–o 7.00); “How likely would you be to refuse palliative care for your family member and choose a curative treatment if there was limited chance the treatment would cure your family member?” (refuse treatment for family member; M = 4.27, SD = 1.70; Range: 1.00–7.00).
Results
Analysis strategy
To examine the possibility of mediation hypothesis we used the PROCESS macro (model 4) (Hayes, Reference Hayes2013). We used a biased-corrected CI 95% to examine the direct and indirect effects based on 5,000 bootstrapped samples. A significant effect is indicated by a confidence interval that does not include zero. Separate models were conducted to examine the relationship between perceived palliative care stigma and each measure of prospective use with negative stereotypes as the mediator. Complete output is presented in Table 1.
Table 1. Mediation model output for effects of palliative care stigma on prospective usage of palliative care for self or family members (study 2, n = 199)
*p = .01; †p = .05. ; Bold text indicates significant effect.
Palliative care stigma model
Perceived palliative care stigma exerted a significant indirect effect via negative stereotypes on each of our four prospective palliative care usage outcomes (Table 1). There was also a significant negative direct effect of perceived palliative care on individuals’ prospective usage of palliative care for themselves if they were dying and their willingness to enroll a dying family member in palliative care. Our model suggests that palliative care stigma is a significant predictor of prospective palliative care usage; this is in part because of the negative stereotypes associated with individuals who use palliative care. (Alternative models were examined in which palliative care stigma was entered as a mediator of the relationship between stereotypes and utilization outcomes. Although the models fit the data, there was only a significant indirect effect of negative stereotypes on the two prospective “use if dying” utilization items via palliative care stigma and these effects were smaller than those witnessed when stereotypes were included as the mediator. Given that our proposed models demonstrate indirect effects on all prospective utilization items, we retained the more parsimonious and theoretically consistent models. Full details of this model can be obtained from the authors.)
Study 2 findings indicate that palliative care stigma predicted less prospective use of palliative care, including being less likely to use it or enroll a family member if dying and being more likely to refuse it or refuse to enroll a family member if curative treatment was an option. These findings support the conceptual framework for stigma that has been modeled in relation to specific medical illnesses, such as lung cancer stigma (Carter-Harris et al., Reference Carter-Harris, Hermann and Schreiber2014), HIV/AIDs stigma (Chesney & Smith Reference Chesney and Smith1999), and mental health stigma (Cooper, Corrigan, & Watson, Reference Cooper, Corrigan and Watson2003; Corrigan, Reference Corrigan2004; Schomerus & Angermeyer, Reference Schomerus and Angermeyer2008). Namely, this prior research demonstrates that health-related stigmas present barriers to seeking and accessing certain forms of medical care. Similarly, the present study indicates that there is a stigma associated with receiving specific treatment regardless of specific medical condition.
Discussion
Taken together, our results advance the research on palliative care stigma by providing experimental evidence that palliative care usage is stigmatized (study 1) and that perceived palliative care predicts decreased prospective use (study 2). Study 1 demonstrated that reading about a terminally ill cancer patient choosing palliative care (vs. chemotherapy) leads to increased negative stereotyping of the patient and more negative evaluations about their treatment decision as well as viewing them as being less afraid of death. Study 2 demonstrated that these same stereotypes about individuals who use palliative care mediate the relationship between perceived palliative care stigma and prospective palliative care use for one's self and one's family. Whereas palliative care stigma has been indicated in qualitative studies with advanced cancer patients and their caregivers (Zimmermann et al., Reference Zimmermann, Swami, Krzyzanowska, Leighl, Rydall, Rodin, Tannock and Hannon2016), the present results provide empirical support for the existence of palliative care stigma. These results help build a framework for what drives potential underutilization of palliative care commonly seen among patients who need it (Cheng et al., Reference Cheng, Willey and Palmer2005).
Specifically, study 1 results indicate that patients who choose palliative care are viewed with more negative stereotypes (e.g., lazy, quitter) and less positive stereotypes (e.g., brave, hero) than those who choose chemotherapy, highlighting the existence of stigma. This builds upon prior research that has demonstrated that “battle” language, such as referring to “fighting the battle against cancer” or “losing the battle,” is prevalent in some forms of serious illness in which palliative care is often needed, such as cancer (Reisfield & Wilson, Reference Reisfield and Wilson2004). Providing further support for this, those who chose palliative care were viewed as being “not afraid of death,” which suggests that palliative care is seen as being for those who are dying. Thus, these perceptions that those who choose palliative care are “losing the battle” or dying could be contributing to the negative stereotypes associated with palliative care use. Furthermore, as demonstrated in study 2, these negative stereotypes may partially drive the relationship between palliative care stigma and less prospective use of palliative care for one's self and one's family members. Thus, the data seemingly indicate that being more likely to view someone who receives palliative care negatively (lazy, quitter) drives the relationship between palliative care stigma and prospective use. The concept that a medical treatment that is deemed valuable and beneficial is stigmatized illuminates a major barrier to providing treatments that may alleviate pain and improve quality of life.
The present results help provide support for the existence of palliative care stigma as well as a clearer conceptual framework for the association between palliative care stigma and prospective palliative care use. The model presented in study 2 is in line with prior social psychological theories and models of health-related stigma (Ablon, Reference Ablon2002; Goffman, Reference Goffman2009; Heatherton et al., Reference Heatherton, Kleck and Hebl2003; Major & O'Brien, Reference Major and O'Brien2005). This model can serve as a conceptual model and framework for testing palliative care as a predictor of actual utilization of palliative care.
Despite the present studies’ many strengths, there are some limitations to consider in interpreting results. One limitation is that all scenarios were hypothetical rather than observing actual patients’ decision-making or actual palliative care use. It would be beneficial to test these concepts in a sample of individuals who make an actual treatment choice or who are more likely to be in a situation in which they must actually determine if they will use palliative care such as those who are seriously ill. Given the dearth of research into palliative care stigma, however, the present studies provide much-needed empirical support for the existence of palliative care stigma. Although the present studies used healthy individual samples, the purpose of the studies was to determine whether palliative care stigma existed (e.g., negative stereotypes) and if it was associated with lower prospective palliative care use. The current studies lay the foundation for future work to examine palliative care stigma among seriously ill patients and their caregivers to determine how palliative care stigma affects intended and actual palliative care use among those who are currently facing palliative care utilization issues. Finally, the present studies do not examine what the possible sources of stigma are (e.g., providers, media). Future studies could examine individuals’ familiarity with and exposure to palliative care to determine where these stigmas have originated. This, in turn, may help guide future interventions designed to target and reduce palliative care stigma and improve utilization of palliative care.
Despite these limitations, the present studies help clarify and examine the largely understudied concept of palliative care stigma and its association with prospective palliative care usage. Both studies’ results highlight the role that stereotypes play in palliative care stigma and its association with prospective usage. Understanding this can help inform future intervention targets. For instance, targeting false stereotypes about individuals receiving palliative care (e.g., as weak, quitter) might be an effective way to improve utilization of palliative care. Future research should examine and test these potential intervention targets. Moreover, future research should also examine whether it is most beneficial to develop palliative care stigma reducing interventions that target the general public or those facing serious illness. Understanding and reducing palliative care stigma has implications for improving the current underutilization of palliative care (Cheng et al., Reference Cheng, Willey and Palmer2005). Given the many benefits afforded to individuals facing serious or chronic illness who use palliative care (Kelley & Morrison, Reference Kelley and Morrison2015; Zimmermann et al., Reference Zimmermann, Swami, Krzyzanowska, Leighl, Rydall, Rodin, Tannock and Hannon2016), it is critical to understand ways to improve utilization. As such, the present studies highlight a promising target for intervention to improve palliative care usage.
Acknowledgments
Dr. Shen's work was supported by the National Cancer Institute (K07 CA207580 Shen). The National Cancer Institute had no role in the study design, collection, analysis, or interpretation of data. All study procedures were approved at each Institution's institutional review board. All procedures were conducted in accordance with required ethical guidelines for protection of human subjects in research. Informed consent was obtained from each participant in the present study.
Conflicts of interest
The authors have no conflicts of interest to report.
Author ORCIDs
Megan Johnson Shen 0000-0001-8006-8459.
Appendix: Palliative Care and Chemotherapy Treatment Conditions
Instructions. Please read the following scenario about an individual's medical condition, treatment options, and final decision regarding treatment. You will later be asked questions about this scenario.
Background. A 50-year-old patient has been diagnosed with stage IV lung cancer. Up to this point in time, the patient has tried two different types of chemotherapy. The first attempt at chemotherapy did not successfully treat the cancer. After that first attempt failed, the patient's oncologist put the patient on a second type of chemotherapy to see if that might treat the cancer. The patient is now having a follow-up appointment with the treating oncologist to discuss results of a recent staging scan the patient had to see if the cancer progressed or shrunk after this second type of chemotherapy finished.
Communication from oncologist. At the appointment, the oncologist communicates the following with the patient:
“Good morning. So today we are reviewing the scan results from your most recent staging scan to see where you are at in regards to your tumor size. As you know, your primary cancer tumor site was at the lung, and that cancer had metastasized to nearby sites, including your liver. We just finished this second round of chemotherapy in hopes that it would shrink the tumors. In looking at your scans here, unfortunately, the cancer seems to have progressed rather than shrunk as I had hoped. Given the results of this scan, it appears that your body is not being responsive to this second line of chemotherapy. Additionally, the cancer sites have now spread to your liver. Given how your body has responded to the chemo for first and second rounds of chemotherapy, the likelihood of curative treatment is now fairly low. That being said, we have a couple of options here. The first option is to continue with a new line of chemotherapy. This chemotherapy would be focused mostly on keeping the tumors from continuing to grow. This, we hope, would help manage your symptoms so that you don't experience too much pain. If we go this route, we would continue to manage the cancer with chemo for as long as we are able. The second option is to consider bringing in the palliative care team, which would be focused on managing your symptoms such as pain and transitioning to comfort care. Comfort care would be focused on making the remaining time you have left as comfortable as possible and to have as high of quality of life as possible. So, given these two options, I want to give you some time to think about it and let me know how you'd like to proceed.”
Treatment decision (palliative care condition). After careful thought, the patient decides to choose palliative care.
Treatment decision (chemotherapy condition). After careful thought, the patient decides to choose continuing chemotherapy.
