Supportive Care in Cancer

, Volume 25, Issue 11, pp 3425–3435 | Cite as

Clinical practice guidelines of the French Association for Supportive Care in Cancer and the French Society for Psycho-oncology: refusal of treatment by adults afflicted with cancer

  • J. C. FaivreEmail author
  • V. Adam
  • V. Block
  • M. Metzger
  • J. Salleron
  • S. Dauchy
Original Article



The study’s purpose was to develop practical guidelines for assessment and management of refusal of treatment by adults afflicted with cancer.


The French Association for Supportive Care in Cancer and the French Society for Psycho-oncology gathered a task force that applied a consensus methodology to draft guidelines studied predisposing situations, the diagnosis, regulatory aspects, and the management of refusal of treatment by adults afflicted with cancer.


We propose five guidelines: (1) be aware of the conditions/profiles of patients most often associated with refusal of treatment so as to adequately underpin the care and support measures; (2) understand the complexity of the process of refusal and knowing how to accurately identify the type and the modalities of the refused treatments; (3) apply a way to systematically analyze refusal, thereby promoting progression from a situation of disaccord toward a consensual decision; (4) devise procedures, according to the legal context, to address refusal of treatment that safeguards the stakeholders in situations of sustained disaccord; and (5) know the indications for ethical collective decision-making.


The quality of the relationship between patients and health professionals, and the communication between them are essential components involved in reaching a point of consent or refusal of treatment. A process of systematic analysis of refusal is recommended as the only way to ensure that all of the physiological, psychological, and contextual elements that are potentially involved are taken into account.


Refusal of treatment Health professional-patient relations/ethics Review Guidelines Neoplasms Decision-making 



We give thanks to Sophie Domingues for the translation into English; S. Rhouni; the task force members: V. Adam et S. Dauchy (scientific coordinator), V. Block (methodologist), F. Barruel-Sinimale, S. Chevallot, M. Delanghe, R. Diab, M. Dionisio, L. Domingo, M. Dubuc, E. Duflot, A. Eberl Marty, J. C. Faivre, E. Gobert, A. Henry, S. Lafon, H. Laval, A. S. Lebihan, I. Lombard, F. Marchal, A. Marhoffer, P. Mathis, T. Montaut, L. Perrin, C. Preaubert-Sicaud, J. Raft, M. Reich, M. Rios, D. Spaeth, E. Thomas Elisabeth, N. Verotte, M. Zamith-Chavant, M. Metzger, and J. Salleron; and the members of the review group: G. Ader, E. Arbiol, E. Bansard, L. Baudin, D. Baudoin, J. M. Bergia, I. Bevilacqua, C. Bigeard, G. Bourgade, P. Brillaxis, M. C. Campergue, Y. Chait, A. Chaix, C. Chauffour-Ader, M. Chrysostome Marion, G. Chvetzoff, P. Colombat, N. Corazza, C. Corra, M. Delanghe, V. Delcroix, C. Deluca, P. Dietrich, M. L. Duhamel, L. Dupont, V. Duport, C. Gallay, E. Gilbert-Fontan, S. Guiberteau, S. Jar, M. C. Joulot, P. Kerdraon, S. Lafon, E. Lemaitre, S. Leriche, L. Lorin-Zurbuch, A. Martin, D. Mayeur, C. Merel-Vevoz, M. Montfort-Kusz, C. Morris, M. Mourceins, A. Parot-Monpetit, N. Piplard, S. Rebois, A. Riff, E. Sardou, V. Simonetti, C. Steckermans-Saez, M. Sulpice, V. Tequi, and D. Thirry.

Contribution of the authors

Administrative support: S. Rhouni, V. Block

Editing of the manuscript: all of the authors

Final approval of the manuscript: all of the authors

Compliance with ethical standards


All of the funding was provided by the AFSOS.

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Liu C-Y, Chen WT-L, Kung P-T et al (2014) Characteristics, survival, and related factors of newly diagnosed colorectal cancer patients refusing cancer treatments under a universal health insurance program. BMC Cancer 14:446. doi: 10.1186/1471-2407-14-446 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Aizer AA, Chen M-H, Parekh A et al (2014) Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiat Oncol Biol Phys 89:756–764. doi: 10.1016/j.ijrobp.2014.03.024 CrossRefPubMedGoogle Scholar
  3. 3.
    Li P, Li F, Fang Y et al (2013) Efficacy, compliance and reasons for refusal of postoperative chemotherapy for elderly patients with colorectal cancer: a retrospective chart review and telephone patient questionnaire. PLoS One 8:e55494. doi: 10.1371/journal.pone.0055494 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Puts MTE, Tapscott B, Fitch M et al (2015) A systematic review of factors influencing older adults’ decision to accept or decline cancer treatment. Cancer Treat Rev 41:197–215. doi: 10.1016/j.ctrv.2014.12.010 CrossRefPubMedGoogle Scholar
  5. 5.
    Berg WA, Blume JD, Adams AM et al (2010) Reasons women at elevated risk of breast cancer refuse breast MR imaging screening: ACRIN 6666. Radiology 254:79–87. doi: 10.1148/radiol.2541090953 CrossRefPubMedGoogle Scholar
  6. 6.
    Rothman MD, Van Ness PH, O’Leary JR, Fried TR (2007) Refusal of medical and surgical interventions by older persons with advanced chronic disease. J Gen Intern Med 22:982–987. doi: 10.1007/s11606-007-0222-4 CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Sinding C, Wiernikowski J (2009) Treatment decision making and its discontents. Soc Work Health Care 48:614–634. doi: 10.1080/00981380902831303 CrossRefPubMedGoogle Scholar
  8. 8.
    Kreling B, Figueiredo MI, Sheppard VL, Mandelblatt JS (2006) A qualitative study of factors affecting chemotherapy use in older women with breast cancer: barriers, promoters, and implications for intervention. Psychooncology 15:1065–1076. doi: 10.1002/pon.1042 CrossRefPubMedGoogle Scholar
  9. 9.
    Ward-Smith P (2003) Brachytherapy for prostate cancer: the patient’s perspective. Urol Nurs 23:213–217PubMedGoogle Scholar
  10. 10.
    Anchisi S, Anchisi A (2008) Going through chemotherapy: an age-revealing process. Bull Cancer (Paris):F44–F50. doi: 10.1684/bdc.2007.0532
  11. 11.
    Schwam ZG, Husain Z, Judson BL (2015) Refusal of postoperative radiotherapy and its association with survival in head and neck cancer. Radiother Oncol 117:343–350. doi: 10.1016/j.radonc.2015.10.013 CrossRefPubMedGoogle Scholar
  12. 12.
    Richert-Boe KE, Weinmann S, Shapiro JA et al (2008) Racial differences in treatment of early-stage prostate cancer. Urology 71:1172–1176. doi: 10.1016/j.urology.2007.10.010 CrossRefPubMedGoogle Scholar
  13. 13.
    Chen SJ, Kung P-T, Huang KH et al (2015) Characteristics of the delayed or refusal therapy in breast cancer patients: a longitudinal population-based study in Taiwan. PLoS One 10:e0131305. doi: 10.1371/journal.pone.0131305 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Puts MTE, Monette J, Girre V et al (2010) Characteristics of older newly diagnosed cancer patients refusing cancer treatments. Support Care Cancer 18:969–974. doi: 10.1007/s00520-010-0883-0 CrossRefPubMedGoogle Scholar
  15. 15.
    Cykert S, Dilworth-Anderson P, Monroe MH et al (2010) Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA 303:2368–2376. doi: 10.1001/jama.2010.793 CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Huang H-L, Kung P-T, Chiu C-F et al (2014) Factors associated with lung cancer patients refusing treatment and their survival: a national cohort study under a universal health insurance in Taiwan. PLoS One 9:e101731. doi: 10.1371/journal.pone.0101731 CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Ciambrone D (2006) Treatment decision-making among older women with breast cancer. J Women Aging 18:31–47. doi: 10.1300/J074v18n04_04 CrossRefPubMedGoogle Scholar
  18. 18.
    Sanders T, Skevington S (2004) Participation as an expression of patient uncertainty: an exploration of bowel cancer consultations. Psychooncology 13:675–688. doi: 10.1002/pon.779 CrossRefPubMedGoogle Scholar
  19. 19.
    Sharf BF, Stelljes LA, Gordon HS (2005) ‘A little bitty spot and I’m a big man’: patients’ perspectives on refusing diagnosis or treatment for lung cancer. Psychooncology 14:636–646. doi: 10.1002/pon.885 CrossRefPubMedGoogle Scholar
  20. 20.
    Tang S-W, Parker H, Winterbottom L et al (2011) Early primary breast cancer in the elderly—pattern of presentation and treatment. Surg Oncol 20:7–12. doi: 10.1016/j.suronc.2009.07.004 CrossRefPubMedGoogle Scholar
  21. 21.
    Verkooijen HM, Fioretta GM, Rapiti E et al (2005) Patients’ refusal of surgery strongly impairs breast cancer survival. Ann Surg 242:276–280CrossRefGoogle Scholar
  22. 22.
    Chouliara Z, Miller M, Stott D et al (2004) Older people with cancer: perceptions and feelings about information, decision-making and treatment—a pilot study. Eur J Oncol Nurs 8:257–261. doi: 10.1016/j.ejon.2003.12.010 CrossRefPubMedGoogle Scholar
  23. 23.
    Crooks DL (2001) Older women with breast cancer: new understandings through grounded theory research. Health Care Women Int 22:99–114. doi: 10.1080/073993301300003108 CrossRefPubMedGoogle Scholar
  24. 24.
    Davison BJ, Oliffe JL, Pickles T, Mroz L (2009) Factors influencing men undertaking active surveillance for the management of low-risk prostate cancer. Oncol Nurs Forum 36:89–96. doi: 10.1188/09.ONF.89-96 CrossRefPubMedGoogle Scholar
  25. 25.
    Denberg TD, Melhado TV, Steiner JF (2006) Patient treatment preferences in localized prostate carcinoma: the influence of emotion, misconception, and anecdote. Cancer 107:620–630. doi: 10.1002/cncr.22033 CrossRefPubMedGoogle Scholar
  26. 26.
    Docherty A, Brothwell CPD, Symons M (2007) The impact of inadequate knowledge on patient and spouse experience of prostate cancer. Cancer Nurs 30:58–63CrossRefGoogle Scholar
  27. 27.
    White MA, Verhoef MJ, Davison BJ et al (2008) Seeking mind, body and spirit healing—why some men with prostate cancer choose CAM (complementary and alternative medicine) over conventional cancer treatments. Integr Med Insights 3:1–11CrossRefGoogle Scholar
  28. 28.
    Lim F, Glynne-Jones R (2011) Chemotherapy/chemoradiation in anal cancer: a systematic review. Cancer Treat Rev 37:520–532. doi: 10.1016/j.ctrv.2011.02.003 CrossRefPubMedGoogle Scholar
  29. 29.
    Oscarsson MG, Wijma BE, Benzein EG (2008) “I do not need to... I do not want to... I do not give it priority...”—why women choose not to attend cervical cancer screening. Health Expect 11:26–34. doi: 10.1111/j.1369-7625.2007.00478.x CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Journal Officiel de la République Française (2002) Loi n° 2002-303 du 4 mars 2002 relative aux droits des malades et à la qualité du système de santé | Legifrance.;jsessionid=FAD55642FC6155464B39BF4BB05E8975.tpdjo06v_2?cidTexte=LEGITEXT000005632379&dateTexte=20120918. Accessed 20 Mar 2017
  31. 31.
    Parker SM, Clayton JM, Hancock K et al (2007) A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J Pain Symptom Manag 34:81–93. doi: 10.1016/j.jpainsymman.2006.09.035 CrossRefGoogle Scholar
  32. 32.
    Hewitson P, Austoker J (2005) Part 2: patient information, informed decision-making and the psycho-social impact of prostate-specific antigen testing. BJU Int 95(Suppl 3):16–32CrossRefGoogle Scholar
  33. 33.
    Hardwick C, Lawson N (1995) The information and learning needs of the caregiving family of the adult patient with cancer. Eur J Cancer Care (Engl) 4:118–121CrossRefGoogle Scholar
  34. 34.
    Hey SP, Truog RD (2015) The question of clinical equipoise and patients’ best interests. AMA J Ethics 17:1108–1115. doi: 10.1001/journalofethics.2015.17.12.ecas1-1512 CrossRefPubMedGoogle Scholar
  35. 35.
    Nishimura A, Carey J, Erwin PJ et al (2013) Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials. BMC Med Ethics 14:28. doi: 10.1186/1472-6939-14-28 CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Jefford M, Moore R (2008) Improvement of informed consent and the quality of consent documents. Lancet Oncol 9:485–493. doi: 10.1016/S1470-2045(08)70128-1 CrossRefPubMedGoogle Scholar
  37. 37.
    Foreman MD, Mion LC, Tryostad L, Fletcher K (1999) Standard of practice protocol: acute confusion/delirium. NICHE Faculty. Geriatr Nurs N Y N 20:147–152CrossRefGoogle Scholar
  38. 38.
    Fiske J, Frenkel H, Griffiths J et al (2006) Guidelines for the development of local standards of oral health care for people with dementia. Gerodontology 23(Suppl 1):5–32. doi: 10.1111/j.1741-2358.2006.00140.x CrossRefPubMedGoogle Scholar
  39. 39.
    Barr J, Fraser GL, Puntillo K et al (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41:263–306. doi: 10.1097/CCM.0b013e3182783b72 CrossRefPubMedGoogle Scholar
  40. 40.
    American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults (2015) Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg 220:136–148.e1. doi: 10.1016/j.jamcollsurg.2014.10.019 CrossRefGoogle Scholar
  41. 41.
    Crocker TF, Smith JK, Skevington SM (2015) Family and professionals underestimate quality of life across diverse cultures and health conditions: systematic review. J Clin Epidemiol 68:584–595. doi: 10.1016/j.jclinepi.2014.12.007 CrossRefPubMedGoogle Scholar
  42. 42.
    Stone L, Blashki G (2000) Integrating counselling into general practice. Aust Fam Physician 29:231–235PubMedGoogle Scholar
  43. 43.
    Journal Officiel de la République Française (2016) LOI n° 2016-87 du 2 février 2016 créant de nouveaux droits en faveur des malades et des personnes en fin de vieGoogle Scholar
  44. 44.
    Alfandre D (2016) Clinical recommendations in medical practice: a proposed framework to reduce bias and improve the quality of medical decisions. J Clin Ethics 27:21–27PubMedGoogle Scholar
  45. 45.
    Noritz G (2015) How can we practice ethical medicine when the evidence is always changing? J Child Neurol 30:1549–1550. doi: 10.1177/0883073814563141 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • J. C. Faivre
    • 1
    Email author
  • V. Adam
    • 2
  • V. Block
    • 3
  • M. Metzger
    • 4
  • J. Salleron
    • 5
  • S. Dauchy
    • 6
    • 7
  1. 1.Academic Department of Radiation Therapy and BrachytherapyLorraine Institute of Cancerology – Alexis-Vautrin CLCC [Centre de lutte contre le cancer – Cancer Center] – UnicancerVandoeuvre-lès-Nancy cedexFrance
  2. 2.Supportive Care in Cancer DepartmentInstitut de Cancérologie de LorraineVandœuvre-lès-NancyFrance
  3. 3.French Association for Supportive Care in CancerParisFrance
  4. 4.Institut de Cancérologie de Lorraine, Medical LibraryVandœuvre-lès-NancyFrance
  5. 5.Biostatistics and Epidemiology DepartmentInstitut de Cancérologie de LorraineVandœuvre-lès-NancyFrance
  6. 6.Gustave Roussy, Département de Soins de SupportUniversité Paris-SaclayVillejuifFrance
  7. 7.ES3, EA1610, Université Paris-SudParisFrance

Personalised recommendations