Patient's refusal of palliative care. A qualitative analysis of the decision-making process leading to dismiss multidisciplinary team proposal in abdominal oncology. The choice to live

In cancer and its spontaneous evolution, hopes are related to medical decisions. Decision-making process has positioned Multidisciplinary Team (MDT) meetings as the main rational factor in order to reach a consensual proposal. Yet, in France, Kouchner and Léonetti laws have given to patients the right to refuse any treatment or investigation including in end-of-life care. Nowadays, a patient in France is allowed to refuse palliative care proposal in spite of MDT conclusions. In order to understand underlying factors leading to a patient refusing a palliative care proposal in malignant context, we performed a retrospective analysis with one surgeon in an academic and tertiary center, from 1995 to 2010. Out of 1000 patients, 0.5% refused a palliative care proposal and decided to undergo a non-consensual surgical procedure in accordance with this surgeon. This management was implemented in patients coming from a well-off and educated background who considered that MDT undervalued their specificities, demonstrated discrepancies in interpretations of the technical feasibility and evidence-based literature. Out of five patients, two are still alive and cured 6 and 18 years after the surgery, respectively. Separation of the Knowledge and the Decision necessitates mediation with the patient and customization related to interindividual variations in order to keep high standards in MDT meetings.