“You must trust and believe in people or life becomes impossible. “
Anton Chekhov “No, Doctor, I don’t have any questions. What do you recommend? I’ll do whatever you tell me to do.”
She looked past me and smiled resignedly. Her adult daughter sat with pen hovering over a spiral-bound pad already overflowing with notes and questions. “When will you get started?”
This was a difficult case with no clear-cut treatment plan. She had an extensive cancer of the jaw. In younger, healthier individuals, this stage of disease is often treated with a complicated surgery, an intricate reconstruction, and then a combination of radiation and chemotherapy. Yet, at 77, she was not robust. My gut told me that she was a poor candidate for either the long surgery or a prolonged treatment course.
Recommending the standard treatment was, it seemed, out of the question — she would never get through it. On the other hand, recommending less intense treatment, although still very challenging, carried lower prospects of ultimate cancer control.
I tried to get her to react to the options. No luck. “I’m not certain, Doctor. What do you think?”
A recent journal article
studied cancer-related decision-making and desire for prognostic information in older adults. A study of 73 recently diagnosed adults with colorectal cancer between 70 years old and 89 years old found that only 30 percent of women and 56 percent of men wanted information on their expected survival times. Over half of the patients adopted a "passive" role in treatment decisions; that is, they agreed with either “I prefer that my doctor make the final decision about treatment, but seriously consider my opinion,”
or “I prefer to leave all decisions regarding treatment to my doctor.”
A quarter of the patients adopted a "collaborative" decision-making posture and a quarter wanted to be "active" decision-makers. Physicians were not consistently able to predict their patients’ decision-making preferences.
This high proportion of passive decision-makers differs between age groups and cancer sites. The paper’s authors point out that cohorts of younger patients and patients with breast cancer have much higher proportions of “collaborative” decision-makers. They remind us to be sensitive to potential differences in the decision-making preferences in our older patients.
In the end, my patient opted for a compromise of a less extensive surgery and post-operative radiation therapy. Although it was, I felt, the best available option, it was a treatment plan that she never questioned. She just let it happen.
Ref: Eiken EB, et al., Desire for Information and Involvement in Treatment Decisions: Elderly Cancer Patients’ Preferences and Their Physicians’ Perceptions, Journal of Clinical Oncology
The following is feedback received for this blog:
I know I like it when patient's "work" with me in making the choices. Yet it must be overwhelming at times from the patient's point of view. I have often tried to imagine what it would be like, how can we not when patient's ask us what we would do in their place. But I truly hope I never have to find out.
- rl bates