Differences in Perspectives and Policies Regarding End-of-Life Care Between Hematologists and Gastroenterologists.

Introduction

Since 2015, multiple studies have highlighted that patients with hematologic malignancies often undergo aggressive treatment until the terminal phase, with limited end‐of‐life (EOL) care [ 1 , 2 , 3 , 4 , 5 ]. Hui et al. [ 6 ] compared hematologists' and solid tumor‐oncologists' attitudes at MD Anderson Cancer Center toward EOL care, finding that hematologists were more likely to prescribe systemic therapy for patients with Eastern Cooperative Oncology Group (ECOG) performance status of 4 and an expected survival of 1 month. They also reported less comfort discussing death, dying, or hospice referrals and were more likely to perceive disease progression as personal failure. By 2011, EOL quality measures—guidelines recommending no chemotherapy, avoidance of intensive care unit admission, and fewer than two hospitalizations in patients with solid tumors—had been proposed [ 3 , 7 , 8 , 9 ]. In 2014, Odejide et al. [ 10 ] reported that hematologists resisted adopting these measures in hematologic cancers. However, a 2016 survey by the same group showed increased acceptance. The highest‐ranked barriers to EOL care transition were “unrealistic patient expectations,” “clinician concern about taking away hope,” and “unrealistic clinician expectations” [ 11 ].

In the United States (US), EOL care is usually provided at home or in inpatient hospice facilities, whereas in Japan, it is generally provided in palliative care wards (PCWs) within hospitals. In the US, many patients with advanced cancer have documented advance care planning (ACP) and widely use hospice services. In contrast, in Japan, the number of patients using PCWs is gradually increasing, and ACP is becoming more common, with expectations that PCW use will continue to expand [ 12 , 13 , 14 ] Japan offers universal health coverage under a distinct medical system [ 15 ], but services resemble US EOL care. Both countries use a fixed daily payment model, comparable to the Medicare Hospice Benefit [ 16 , 17 ].

A decade has passed since Hui et al. [ 6 ] published the only direct comparison of hematologists and solid tumor‐oncologists regarding EOL care. Since then, novel therapies—including molecularly targeted agents, immune checkpoint inhibitors [ 18 ], Chimeric Antigen Receptor (CAR) T‐cell therapy [ 19 , 20 ], and bispecific antibodies [ 21 , 22 ]—have emerged. These advances may have changed physicians' perspectives [ 23 , 24 ].

Gastrointestinal cancers account for a disproportionately large share of the global solid‐tumor burden [ 25 ]. Japan is no exception; gastroenterologists treat the largest number of patients with solid tumors among solid‐tumor oncologists. Therefore, we considered it reasonable to use gastroenterologists as the comparison group for hematologists. Furthermore, conducting a survey targeting all solid tumor oncologists, including gastroenterologists, for comparison with hematologists was deemed practically impossible because the survey size would have become excessively large.

In Japan, several studies [ 26 , 27 ] have reported that patients with hematologic malignancies account for a substantially smaller proportion of admissions to PCWs than patients with solid tumors and are more likely to die in acute care wards rather than in PCWs.

Accordingly, we conducted a questionnaire survey of hematologists and gastroenterologists, building on Hui et al. [ 6 ] with additional items, to compare current perspectives and policies toward EOL care.

Methods

Survey Design and Development

Ethical approval was obtained from the Research Review Board of Higashi Sapporo Hospital (Study ID: medical ethics Ro‐9). We administered a questionnaire to hematologists and gastroenterologists to explore the reasons underlying the reported lower rate of admission of patients with hematologic malignancies to PCWs (palliative care wards) (palliative care hospitals [PCHs]) during EOL care compared with patients with gastrointestinal cancers. A cover letter containing the random three‐digit department number and titled “Fact‐finding survey (Questionnaire survey) on differences between hematologists and gastroenterologists regarding perspectives and policies for EOL care of cancer patients”, was mailed to departments responsible for anticancer drug therapy for hematologic or gastrointestinal cancers in Japanese health care facilities. In line with ethical guidelines, the letter explained the study. The 50‐item questionnaire was administered via Google Forms, with informed consent obtained within the questionnaire under Japanese “Ethical Guidelines for Medical and Biological Research Involving Human Subject” [ 28 ]. Responses to the survey were compared between the two groups. The EOL period defined in the survey did not specify a particular timeframe. The survey was conducted anonymously. The survey period was from April 18, 2025, to June 9, 2025. During this period, we sent one reminder.

Facilities

The survey for hematologists was carried out with 19 hematology departments belonging to the North Japan Hematology Study Group (NJHSG) and 9 hematology departments not affiliated with NJHSG. The survey for gastroenterologists was carried out with 31 gastroenterology departments, including the same 9 university hospitals that were requested to participate in the survey for hematologists.

Survey Instrument

The survey consisted of 50 mandatory questions covering physicians' demographics, clinical practice patterns, and perspectives on EOL care. The full English and Japanese versions of the questionnaire are provided in the Data S1 . The questionnaire incorporated previously published items from Hui et al. [ 6 ], including questions on referral patterns to PCWs, case vignettes [ 6 , 29 ] assessing willingness to administer anticancer therapy in patients with limited life expectancy, and beliefs and attitudes toward EOL care [ 6 , 30 ]. It also included items regarding EOL quality measures [ 10 , 11 ] and perceived barriers to EOL care based on prior work by Odejide et al. [ 11 ]. Additional items were developed by the authors to explore factors specific to the Japanese healthcare system that may influence referrals to PCWs and PCHs, such as the availability of transfusions and other medical technologies in these settings. Representative domains included: (1) proportion of patients referred to PCWs/PCHs in routine practice; (2) willingness to administer anticancer therapy to hypothetical patients with poor performance status and limited expected survival; and (3) perceived barriers to timely transition to EOL care. All questions were presented in Japanese. The EOL period was not defined by a specific timeframe within the questionnaire. The survey could not be completed unless all questions were answered. In the questionnaire, Questions 6–9, 14, 15, 31–41 were adopted from Hui et al. [ 6 ], Questions 10, 11, 13, 20–27, 44–50 were based on Odejide et al. [ 10 , 11 ], and Questions 1–5, 12, 16–19, 28–30, 42, 43 were newly developed by the authors (Data S2 ).

Statistical Analysis

Categorical variables were compared using the chi‐square (χ 2 ) test. Significance was defined as a p < 0.05. Physicians' perceptions of medical technologies not commonly performed in PCWs were summarized using proportions and 95% confidence intervals. All analyses were performed using JMP Student Edition version 18.2.2 (JMP Statistical Discovery LLC, Cary, NC, USA).

Results

Number of Physicians Who Answered the Survey

We confirmed that no respondent answered the survey multiple times, as there were no identical responses in the randomly allocated three‐digit department number, age, sex, specialty (hematology or gastroenterology), years of clinical experience, possession of specialist qualifications, and other similar information. We obtained responses from 121 hematologists treating blood cancers and 141 gastroenterologists who treat gastrointestinal cancers, including eight medical oncologists treating both. For analysis, hematologists were compared with 141 gastroenterologists. At the surveyed facilities, there were 240 hematologists and 393 gastroenterologists, resulting in questionnaire response rates of 50.4% and 35.9%, respectively.

Characteristics of Participating Physicians

Table 1 summarizes physician characteristics. About 56% of hematologists and gastroenterologists worked in tertiary medical institutions.

The Primary Reason for Transferring Cancer Patients From the Acute Care Ward to PCW (PCH)

The leading reason for transfer to EOL care was refractory to standard therapy for cancer. Hematologists and gastroenterologists reported this, with no group differences. Full details are presented in Table S1 .

The Percentage of Patients Transferred to PCW ( PCH ) and Registration for Clinical Trials for Relapsed/Refractory Patients After Chemotherapy

Physicians transferring ≥ 21% of patients to PCW or PCH were fewer among hematologists than gastroenterologists (6.6% vs. 37.5%, p < 0.0001). Conversely, more hematologists practice enrolling relapsed/refractory patients after anticancer drug therapy into clinical trials than gastroenterologists (81.0% vs. 46.1%, p < 0.0001).

Anticancer Drug Therapy Preferences

Table 2 shows differences in willingness to treat four hypothetical patients. A higher percentage of hematologists than gastroenterologists indicated that they would administer anticancer drug therapy to all four cases.

Reasons Why Patients With Cancer Cannot Be Transferred From the Acute Care Wards to the PCW ( PCH )

Using multiple‐choice responses (Figure 1A ), physicians identified medical technologies rarely performed in PCWs or PCHs in Japanese hospitals. Platelet transfusions ranked highest among hematologists, who also reported platelet and red blood cell transfusions more frequently than gastroenterologists. Items exceeding 50% in both groups included vasopressors and drugs for disseminated intravascular coagulation (DIC), with no group difference. However, computed tomography scans were reported as 0% in both groups. Additionally, more gastroenterologists than hematologists responded that “there are no medical technologies that are not performed”. Compared to gastroenterologists, more hematologists (68%) declined transfer because the PCWs or PCHs lacked the required technologies (Figure 1B ).

Acceptability of Quality Measures, and no Administration of Broad‐Spectrum Antibiotics, Vasopressors, or DIC Treatment Drugs in the Last 30 Days of Life

Compared with gastroenterologists, hematologists reported lower acceptability of the following: no chemotherapy within 14 days of death, no red cell and platelet transfusions within 7 days of death, no vasopressor administration and DIC treatment in the last 30 days of life (Figure 2 ).

Beliefs and Attitudes Toward EOL Care

Hematologists were more reluctant than gastroenterologists to refer patients to PCWs or PCHs. However, they were more likely to refer patients based on advanced age (Table 3 ).

Perceived Barriers to End‐Of‐Life Care

The top three barriers were unrealistic patient expectations, physician uncertainty about prognosis, and lack of physician time. These were common to both groups, with no significant differences (Figure 3 ).

Discussion

This survey directly compared hematologists and gastroenterologists regarding EOL care. Issues related to the validity of our results are discussed below.

Perspectives and Policies of Hematologists That Have Not Changed Since 2015

We adopted the same questions on the use of anticancer drug therapy in EOL and on attitudes and beliefs regarding EOL care as those formulated by Hui et al. [ 6 ]—the only study directly comparing hematologists and solid tumor‐oncologists. A greater proportion of hematologists than gastroenterologists demonstrated a proactive attitude toward administering anticancer therapy to patients with an expected survival of 1 month and an ECOG performance status of 4; they also reported difficulty referring patients to a PCW or PCH. These findings align with Hui et al. [ 6 ] supporting the validity of our results and indicating that attitudes of hematologists toward EOL care have remained unchanged for the past decade. Multiple reports by Hui et al. [ 31 , 32 , 33 ] show that patients with hematologic malignancies more frequently receive systemic therapy, including chemotherapy, during EOL than patients with advanced solid tumors. In patients with limited life expectancy and poor performance status, assessing survival benefit from anticancer therapy is difficult, and carefully designed observational studies are necessary. We could not identify why hematologists are less able than gastroenterologists to refer patients to PCWs or PCHs. Meanwhile, research suggests that integrating palliative care with oncology—particularly for hematologic malignancies, such as acute myeloid leukemia—improves transition to EOL care [ 34 , 35 ]. Educational campaigns on integrated palliative‐oncology care may therefore be beneficial in Japan.

The Unpredictable Course of Blood Cancers Makes a Timely Transition to EOL Care Difficult

The most common reason for transitioning to EOL care was refractory to standard therapy for cancer, and no significant difference was observed between hematologists and gastroenterologists. Below is a discussion about the correlation between the results and the higher proportion of hematologists compared to gastroenterologists who responded that they would administer anticancer drug therapy to all four hypothetical patients in the case vignettes shown in Table 2 . Blood cancers are categorized into two groups: aggressive hematological malignancies (“the rollercoaster”), including acute leukemia, aggressive lymphoma, and patients undergoing HSCT; and indolent hematological malignancies (“the war of attrition”), including chronic lymphocytic leukemia, indolent lymphoma, and multiple myeloma [ 35 ]. As reported by Odejide et al. [ 10 ] defining EOL as a life expectancy of ≤ 6 months, refractory disease after anticancer drug therapy, or relapse after HSCT may indicate a switch to EOL care in both groups. Notably, 98.3% of hematologists supported continuing anticancer therapy in patients with a 6‐month prognosis and ECOG performance status of 2. This indicates that many hematologists still pursue intensive anticancer therapies such as CAR T‐cell therapy [ 19 , 20 ], bispecific antibodies [ 21 , 22 ], and HSCT to relapsed/refractory patients. While these therapies may induce severe cytopenia, infections, and even sudden death, recovery is sometimes achieved with supportive therapies such as blood transfusion [ 10 , 35 ]. The unpredictable course of blood cancers makes a timely transition to EOL care particularly difficult for hematologists [ 36 ]. Another study reported that over 50% of patients with hematologic malignancies who died after CAR T‐cell therapy were hospitalized in the last 30 days of life, and most of them died in hospitals or medical facilities rather than in hospices [ 20 ]. Among patients with multiple myeloma who were administered bispecific antibodies, 62% developed infections affecting their clinical management with a median time from initiation of bispecific antibodies of 49 days, 56% were hospitalized, and 9% died [ 22 ]. Hence, determining the timing of transition to EOL care in patients with hematologic malignancies remains difficult, even with the definition of EOL as ≤ 30 days. CAR T‐cell therapy, bispecific antibodies, and HSCT may be standard treatments by many hematologists [ 23 , 24 ]. Thus, determining the appropriate timing for transitioning to EOL care in patients with hematologic malignancies has become more challenging because of the clinical introduction of CAR T‐cell therapy and bispecific antibodies compared to a decade ago. In contrast, gastroenterologists, knowing that salvage therapy does not provide a curative option for patients with relapsed/refractory disease after standard chemotherapy, may be more inclined than hematologists to transition to EOL care.

Treatment‐Related Deaths and Deaths Unrelated to Underlying Diseases in Blood Cancers May Make a Timely Transition to EOL Care Difficult

The following discussion addresses results showing that, compared with gastroenterologists, hematologists are less willing to omit red blood cell or platelet transfusions within 7 days, as assessed by EOL quality measures. Burstein et al. [ 37 ] reported that patients with blood cancers have higher mortality rates from treatment‐related complications and causes unrelated to underlying diseases than patients with solid tumors. They also demonstrated that in the 2 weeks before death, patients with blood cancers more frequently received mechanical ventilation, red blood cell transfusions, and platelet transfusions than patients with solid tumors. In other words, the risk of treatment‐related deaths or deaths unrelated to underlying diseases may be associated with intensive medical interventions during the EOL period in patients with hematologic malignancies. Therefore, timing the transition of patients with blood cancer to EOL care is more challenging than for patients with solid tumors, raising concerns about whether EOL quality measures developed based on data from patients with solid tumors are appropriate indicators for evaluating the quality of EOL care in patients with blood cancer.

Enrolling Patients With Relapsed/Refractory Disease After Anticancer Drug Therapy in Blood Cancers Into Clinical Trials May Make a Timely Transition to EOL Care Difficult

The finding that a significantly higher proportion of gastroenterologists than hematologists transferred ≥ 21% of their patients to PCWs (PCHs) was as we had expected. More hematologists enroll relapsed/refractory patients after anticancer drug therapy into clinical trials compared to gastroenterologists. If enrolling patients with relapsed/refractory disease after anticancer drug therapy into clinical trials is a factor hindering the timely transition of patients with hematologic malignancies to EOL care, eliminating this practice could prevent the development of potentially promising future treatments; therefore, it may not represent a realistic solution.

Transfusion in Blood Cancers Make a Timely Transition to EOL Care Difficult

Compared with gastroenterologists, hematologists were more likely to believe that transfusions generally cannot be administered in PCWs or PCHs. They were also more likely to discontinue transitioning patients to EOL care because medical techniques that are not commonly used in PCWs or PCHs must be performed in acute care wards. In Japan, no medical techniques are prohibited in PCWs under the national medical system. The daily payment amount is uniformly fixed, similar to hospice care provided under the Medicare Hospice Benefit in the US. PCWs in Japan tend to refrain from administering transfusions because of their high cost and the resulting impact on hospital expenses, which is reflected in the questionnaire responses. A recent Japanese study [ 27 ] evaluating patients with hematologic malignancies admitted to a PCW reported that these patients accounted for only a small proportion of total PCW admissions and were often referred at a late stage of disease. This observation aligns with our findings and suggests that structural barriers, including transfusion‐related concerns, may contribute to delayed or limited access to PCWs for patients with hematologic malignancies. Platelet transfusions are distinctly expensive, and as anticipated, hematologists were more likely than gastroenterologists to indicate that the high cost of platelet transfusions and the inability to administer them in PCWs prevented patients from being transferred from acute care wards to PCWs. However, evidence regarding platelet transfusions in EOL care is very limited, and their effectiveness remains debated [ 38 ]. Prospective studies and clinical trials are needed to clarify the usefulness of blood transfusions in EOL care for patients with hematologic malignancies. This study also indicated that gastroenterologists generally do not consider transfusions necessary for cancer patients during EOL care.

Perceived Barriers to EOL Care

The top three perceived barriers to EOL care were unrealistic patient expectations, physician uncertainty about prognosis, and lack of physician time, with no significant differences between hematologists and gastroenterologists. The inability to accurately predict the prognosis of patients with hematologic malignancies is attributed to the unpredictable disease trajectory unique to blood cancers, as mentioned above. In contrast, gastroenterologists are aware that salvage therapy does not provide a curative option for relapsed/refractory patients after standard systemic cancer therapy; it is speculated that this does not mean they can accurately predict the exact time of death for each patient with gastrointestinal cancers. The high ranking of “physician uncertainty about prognosis” and “lack of physician time” among barriers to EOL care suggests that managing unrealistic patient expectations is difficult. Although hematologists are often unable to make definitive prognostic judgments, discussing prognosis in terms of best‐case and worst‐case scenarios with patients and their families—using communication methods such as the Best Case/Worst Case communication tool [ 39 ]—has been reported to be useful in setting realistic expectations; however, in practice, it appears to be difficult. Further research is required to explore why a higher proportion of gastroenterologists than hematologists transition patients with cancer to EOL care, despite both groups acknowledging unrealistic patient expectations as a barrier. Previous research indicated that hematologists cited a lack of time as a barrier [ 40 ].

Limitations

The study has some limitations. First, several items in our questionnaire—including those adopted from Hui et al.—have not undergone psychometric validation, and the original study by Hui et al. did not report reliability testing of the survey instrument. Therefore, the reliability and validity of certain items remain uncertain. In addition, the items newly developed for this study were not pre‐tested or validated before administration. These issues may have introduced measurement bias. Second, the survey response rate was not 100%, and non‐respondents may have introduced bias. Third, we used case vignettes to evaluate decisions for anticancer drug therapy. This approach may not accurately reflect complex decision‐making processes in real clinical practice. Fourth, the study did not include hematology subspecialties of hematologists (leukemia, malignant lymphoma, multiple myeloma, and HSCT) and gastroenterology subspecialties of gastroenterologists (digestive tract, liver, and pancreas). The perspectives and policies of physicians on EOL care may differ depending on their subspecialties. Fifth, the study did not assess the physicians' proficiency in palliative care. The perspectives and policies on EOL care may vary depending on the level of training and proficiency in palliative care.

Conclusions

The study confirmed its validity but also showed that hematologists' attitudes and beliefs regarding EOL care have remained unchanged for a decade, creating a barrier to EOL care transition in patients with hematologic malignancies. Additional findings indicate that interventions such as enrollment in clinical trials and transfusions may also delay this transition. Patients with blood cancer experience treatment‐related deaths and deaths unrelated to underlying diseases more frequently than patients with solid tumors, which likely contributes to delayed EOL care. Furthermore, the transition to EOL care for these patients has become more challenging compared with 10 years ago because of the introduction of novel therapies such as CAR T‐cell therapy and bispecific antibodies. However, hematologists should recognize that clinical studies and real‐world clinical practice differ when new treatment methods are introduced. Hence, hematologists should develop perspectives that account for the use of limited medical resources. Future efforts should focus on increasing the number of patients who transition to EOL care through measures such as early integration of palliative care into the overall treatment process.

Author Contributions

Takuya Matsunaga: conceptualization, investigation, methodology, writing – original draft, writing – review and editing, validation. Takayuki Machino: conceptualization, writing – review and editing, methodology, validation, writing – original draft. Ken Sato: conceptualization, writing – review and editing, methodology, validation, writing – original draft. Masayoshi Kobune: conceptualization, writing – review and editing, methodology, validation, writing – original draft. Kohichi Takada: conceptualization, writing – original draft, writing – review and editing, methodology, investigation, validation. Yusuke Sugama: conceptualization, writing – review and editing, methodology, validation, writing – original draft. Shiro Hinotsu: formal analysis, writing – original draft, writing – review and editing, conceptualization, methodology, validation. Takanori Teshima: conceptualization, writing – review and editing, methodology, investigation, writing – original draft. Kazuyuki Murase: conceptualization, investigation, writing – original draft, writing – review and editing, methodology, validation. Yasuhiro Nagaoka: conceptualization, writing – review and editing, methodology, validation, writing – original draft. Kunihiko Ishitani: conceptualization, writing – original draft, writing – review and editing, methodology, investigation, validation, supervision, project administration.

Disclosure

Hematologists continue to pursue intensive anticancer therapy and face greater challenges in transitioning patients with hematologic malignancies to end‐of‐life care compared to gastroenterologists. These differences are influenced by reliance on transfusions, clinical trial enrollment, and limited referral to palliative care wards, with little change in attitudes over the past decade.

Ethics Statement

Ethical approval was obtained from the Research Review Board of Higashi Sapporo Hospital (Study ID: medical ethics Ro‐9).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: The primary reason for transferring cancer patients from the acute care ward to the palliative care ward (palliative care hospital).

Data S1: supporting Information.

Data S2: supporting Information.

Acknowledgments

The authors thank all the physicians who responded to the survey and Editage ( www.editage.com ) for English language editing. All authors have declared that no financial support was received from any organization for the submitted work.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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