The Hidden Dilemmas of Immunotherapy in Patients With Melanoma at End-of-life

Outcomes

1. Participants will be able to identify ethical challenges in delivery end-of-life care for patient on concurrent immunotherapy.

2. Participants will be able to describe ways in which different interdisciplinary team members can attempt to address and mitigate moral injury experienced by patients, families, and healthcare teams in ethically challenging situations.

Key Message

Patients with metastatic melanoma on palliative immunotherapy face dilemmas at end-of-life that affect symptom management, care options, and risk of moral injury. Interdisciplinary collaboration is key for quality patient care in these situations to ensure patient autonomy and to meet best practices for goal-aligned care and shared decision making.

Abstract

Treatment for melanoma has changed since the introduction of immunotherapy in the 1990s. Since then, the median survival rate has improved from 6 months to nearly 6 years for patients with metastatic melanoma. Despite this, the 5-year survival rate remains low at 30% (1). These statistics have led to more patients with metastatic melanoma on immunotherapy at end-of-life (EOL).

Session Format

We will use a case-based debate to explore the challenges in honoring patient autonomy, goal-aligned care, and shared decision making for patients on immunotherapy at EOL. Dilemmas include the role of palliative immunotherapy to mitigate rapid disease progression at EOL, symptom management challenges created with concurrent immunotherapy, and the impact of ongoing immunotherapy on hospice eligibility. To highlight challenges involved in EOL care for this unique patient subset, a physician and a pharmacist will explore the following questions for a patient with metastatic melanoma and multiple psychosocial burdens: If immunotherapy is used to mitigate the symptom burden from disease progression but is also rendering analgesics ineffective, should we consider stopping immunotherapy to achieve better symptom control? What should we do if there are no acceptable pain management modalities when the plan is to continue palliative immunotherapy? Can a patient be hospice eligible while continuing palliative immunotherapy? If a patient is not hospice eligible, should we stop immunotherapy to achieve eligibility? What are the ethical implications if stopping immunotherapy accelerates disease progression? How do we address the moral injury clinicians face when navigating these dilemmas? Takeaways: Increased immunotherapy options for patients with metastatic melanoma introduces new and difficult questions for patients, families and healthcare teams at EOL. Our panelists will explore questions that teams may encounter in this patient population. Learners will leave empowered with knowledge and skills to navigate similar challenging conversations as patients approach EOL.

References

1. Knight A, Karapetyan L, Kirkwood JM. Immunotherapy in melanoma: recent advances and future directions. Cancers (Basel). 2023;15(3): 1106.