Therapeutic inertia near the end of life in advanced cancer: a narrative review and framework

Abstract

Advanced cancer requires repeated decisions about whether further cancer-directed treatment remains proportionate. This narrative review examines therapeutic inertia near the end of life, defined as treatment continuation or initiation by the treating team without explicit reassessment after prognosis, functional status, or patient priorities change. A narrative design integrated clinical, qualitative, ethical, policy, and health-informatics evidence. A search of PubMed, professional-society websites, and standards resources covered English-language publications from 1 January 2015 to 23 April 2026, and older seminal sources were retained. Thirty-eight sources were included; one was a previously published Brazilian retrospective cohort from the author group, and no patient-level data were reanalyzed. Three themes emerged: late treatment is sustained by prognostic uncertainty, action bias, and treatment momentum; advance care planning is most useful when culturally sensitive, iterative, and linked to a concrete care plan; and electronic health record documentation is most actionable when brief, visible, and integrated into workflow. A proposed five-question framework links goal, time to benefit, burden, patient understanding and values, and documentation. These safeguards may support proportionate care without equating treatment limitation with abandonment.