Is collusion necessary? A commentary on necessary collusion.

The argument made by Helft in favor of “necessary collusion” in the discussion of prognosis between patients with cancer and their oncologists is predicated on the presumption that the primary goal of oncologic care is to maintain hope. If this were the case, then it would be difficult to argue against such an approach. However, the primary goal of oncologic service is to care for patients with cancer in a comprehensive manner, with appropriate attention paid to their physical, psychological, and practical needs. Helping patients maintain hope is but one part of this, not the core principle. In order for patients to make rational decisions regarding their treatment, they need to understand the nature of their illness, particularly with regard to how the disease will affect their lives. A clear discussion of the goals of treatment, which inherently must touch on prognosis, is a key factor in this equation. The most important aspect of prognosis that patients must understand to participate in medical decision-making is whether or not the practical goal of treatment is cure. If not, then patients need to be told up front that their disease is not considered curable with currently available therapy. Of course, as noted by Helft, there is the major issue of medical uncertainty, and in light of this reality, a good rule of thumb is to “never say never, never say always.” Along these lines, it is medically dishonest to give someone a quantitative prognosis when they are initially diagnosed with cancer, as it is impossible for us to know how long any one individual will live. Median survival is not meaningful to the individual patient, whereas an honest statement of interval survival (eg, “X percent of people live longer than 1 year and X percent live longer than 2 years”) can provide them with a clear notion of the seriousness of their disease, while also affording them the hope of open-endedness. As pointed out by Groopman, we can all relate stories of our rare outliers who have proven the textbooks wrong. While it may be appropriate to share such optimistic tales with patients, it is necessary to qualify such vignettes with objective measures of probability. It is good to hope for a miracle, but care of the patient with advanced disease can become very difficult when they are led to expect a miracle. It is in the practical application that “necessary collusion” meets its biggest challenges. Patients with a terminal illness need time not only to come to terms with their spiritual being, but also to see to the practical matters in their daily lives. Arrangements may need to be made on the management of the family business or the care of young children or older parents. Lack of honesty regarding prognosis can lead to devastating financial and social consequences when such decisions are put off until it is too late. A related practical concern with collusion is that many patients with advanced cancer suffer precipitous declines in their functional status that preclude the measured use of “forecasting” as proposed by Helft. In such From the Division of Hematology/ Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.