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

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.

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.

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.").

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.