Understanding “Patient refuses” among 90+ year old patients with cancer or presumed cancer

Objectives: Patients who are 90+ years of age are a growing – but understudied – group at risk for cancer. Because many of these patients are undertreated (with no tissue/cytologic diagnosis), we sought to better understand how such decisions are arrived upon. Methods: This study focused on patients between 2007 and 2017. None had received cancer therapy. Medical records were reviewed for quotations relevant to decision-making and analyzed qualitatively. Results: Ninety-four patients (median age 93 years) with a cancer diagnosis/presumed diagnosis were identified; most were women (82%) with an average of six co-morbidities (dementia occurred in approximately one-third). The primary qualitative theme was a keen appreciation on the part of all stakeholders of the gravity of the decision to forgo a cancer work-up/therapy, with four subthemes: 1) substantial, detailed medical information about the patient's medical condition (“600 mL of yellow, hazy fluid with an LDH [lactate dehydrogenase] level greater than 450 …”); 2) complex discussions about the risks and benefits of no biopsy and/or no cancer treatment (“[the patient] would not prefer to have the quality of any remaining time ruined with salvage chemo and radiation”); 3) the inclusion of multiple individuals in decision-making (“I had a lengthy discussion with the patient and her daughter;” “I spoke by phone with one of my pathology colleagues”); and 4) patient-voiced decision-making (“I want to die.”). Conclusion: Healthcare providers appear to understand the seriousness of no cancer-directed therapy and no work-up in patients 90 years of age and older. Neither ageism nor nihilism was observed.