Monday, December 20, 2004

When is No Treatment the Right Treatment?

Imagine yourself the son or daughter of a hard-working man who put in his years of labor and skill without complaining, a father who in his day could hoist you and your squealing brother up over his shoulders with ease, a husband who adored his wife but couldn't say so, a master griller in summertime, a buddy to his buddies, a die-hard fan...

...and a man who loved his cigarettes.

Imagine now sitting beside him in a dreary hospital room as he labors for breath and strength, crushed under the weight of that disease which silently grew within him, only to burst forth like a sudden flame from smoldering embers.

How would you react if the medical oncologist on the case recommended not treating your father's cancer? This seems incompatible with the healing art, which exists only to improve the life of one who suffers. What is behind such a decision?

I often see patients who have lost the ability to take care of the daily activities we all take for granted, such as dressing oneself, because of the beating cancer inflicts on the body. An even worse scenario is when cancer unites with a chronic illness such as emphysema, which can rapidly drain whatever meager reserve the patient has left. In order to reverse this decline the cancer must be stopped, which usually requires the use of chemotherapy. The risk of complications and death from chemotherapy in a weakened person is high. It is a risk that in many cases cannot be hazarded, and withholding treatment then will not only prevent toxicity but spare the patient from becoming a statistic loathed by all oncologists - a "treatment-related mortality".

Withholding treatment, however, means that the cancer will still grow. This paradox is just one example of how cancer harbors its own unique form of distress for the patient and family - and for the oncologist who is now hindered in the wielding of his therapeutic sword. This choice must be considered, though. I have seen many a patient start out on chemotherapy with the highest of expectations only to die the next week from immunosupression.

Which option is worse, then - letting the cancer progress and avoiding the risks of treatment, or taking a chance on chemotherapy and an early demise?

Oncologists live with this dilemma every day, and when we make a final decision it is not imperiously like Solomon in his temple, but in concert with the patient and loved ones. The task is not easy but is vincible if four straightforward questions are asked:

1. What does the patient want? (if he or she cannot answer the reason why is usually not encouraging - cf. comatose)

2. What are the chances that the treatment will reduce the cancer? (anything less than 20% is typically not worth the risk)

3. Is life prolonged on this treatment, compared to providing supportive care only? (an answer of "no" is a compelling argument against)

4. What is the risk of severe toxicity and death? (patients who are bedridden, or spend most of their waking hours at rest are at higher risk)

All it takes is one conference...or two...or three or more, and soon the right decision will be manifest. As an oncologist I can provide informed consent and (purportedly) sage counseling, both of which will hopefully lead to a choice that is acceptable to all. Throughout this process, whether the discussion goes smoothly or painfully, my obligation to the patient will be more likely to be fulfilled if I follow one of the Laws contained in that classic satire on medicine, Samuel Shem's novel The House of God:

"The patient is the one with the disease."

...and the doctor is merely his servant.


At 2:36 PM, Blogger kdt said...

Five years ago, my father lay in ICU on a ventilator. He had been diagnosed that same week with small cell lung cancer, only to have an aortic aneurysm rupture days later. As he slowly recovered from surgery to repair the aneurysm, he developed sepsis in ICU and several times we were told he might not make it. The ventilator breathed for him for more than a month. He lost over 35 pounds.

The oncologist said that chemo would kill him in that state. Yes, I understood that; however, logic provided absolutely no comfort as I desperately wanted to help my dad the only time I ever remembering him needing it.

Isn't it remarkable that, even though his body was so sick and weak, the cancer was still able to thrive?

Side note: I remember a Craig Hildreth in some English classes at Iowa State. He was a Sig Ep who I think might have gone on to medical school. Might that person be you?

At 5:51 PM, Anonymous Anonymous said...

I also remember the feelings of helplessness, as I watched my mother rapidly lose her fight with lung cancer.

In her case, she had never smoked a day in her life. She never liked the smell of cigarette smoke, and I never understood how she and my father got together, as she was quite the vocal anti-smoker. My father, however, had smoked 3-4 packs a day from the time he was 14.
I also understood the power of nicotine addiction better, when, even as he saw his wife of 24 years dying of lung cancer at the age of 43, he still could not quit. He had to smoke outside, since she was on oxygen, but, even though he cut way down, he still could not quit completely.

Sadly, almost a year to the day after she died, he died of a heart attack, or a broken heart..

I think another question that should be asked by a pending chemo patient, is, "will the time that chemo buys me be a life worth living, or just an extension of my misery." I know it isn't every case, but many times I meet cancer patients, who are frail, sick, and bedridden from the chemo. I remember my mothr, swollen, confused, and miserable. Yes, I know she was fighting, but they never gave us much hope. Was the extra six months worth it?


At 11:16 PM, Blogger Dr. Craig Hildreth said...

To kdt:

Your memory is excellent - I am the same person you knew at ISU. But who are you, and how did we know each other? Feel free to email me, before the suspense kills me...

To John:

This is one of the most difficult scenarios in my field - when do we decide to quit treatment and concentrate on keeping the patient comfortable? I try to emphasize to my families that it is okay to stop chemotherapy, that a patient's life means more than being a punching bag for the oncologist's whims of treatment.

At 12:30 AM, Blogger Katie said...

Dr. Hildreth, Can you teach our medical ethics and doctoring classes??? Your blog is a medical education in itself.
As always, thanks for your thoughtful, thought-provoking posts!

At 8:59 AM, Blogger APeticola said...

I don't get it, in all honesty. To me it is a fairly easy choice not to pursue an obnoxious and not-very-effective treatment. (If it were a harmless and not-very-effective treatment, that's different.) Doesn't make me feel better about death, illness, or anything. But why do most people so fervently want to "do something"?
I am one of five children and my father developed lung cancer at age 85 (he had smoked a bit, but long long before, not related I would guess). Because he was not going to treat, he did not even have a biopsy.
My mother five years later at the same age after a hip surgery was in acute pain, unable to do rehab, and turned out she had probable cancer in the bone, who knows from where. She too refused a biopsy or treatment.
Both had hospice treatment and died at home. My father's hospice treatment was only so-so, but he did fairly well until a pretty bad last couple of months (partly because he had reservations about asking for pain meds, though he eventually took some), my mother's care from a different hospice was extremely supportive and she had a mostly very enjoyable half-year during which she felt so well (because of adequate pain medication) that both she and the hospice people started doubting she had cancer, then died rather quickly with a miserable couple of days including unpleasant delirium and a week's coma.
There were no family differences that this was how to go. Treatment would be better? I don't think so.
I do remember the hospice people were somewhat surprised we didn't panic and take her to a doctor or hospital at the end but we knew she didn't want that.

At 11:03 PM, Blogger Jan said...

If only all oncologists approached chemotherapy with your viewpoint.
When my mother was dying from a peripheral T cell NHL w/ brain mets her oncologist had the nerve to suggest that she might be a candidate for a stem cell transplant at Stanford. He even made the referral. I knew that my mother, who had developed pulmonary fibrosis from her CHOP and had CAD w/ occlusion of 2 of her bypass grafts done 1 year prior, was not a candidate. But rather than be the rational medical professional that I am and recommend against the transplant eval, I had to be the supportive daughter. Of course they declined her (but also determined that she had likely developed a leukemic transformation). Shortly thereafter we (my brother and I) called the oncologist and basically told him to quit looking thru rose colored glasses and holding out carrots (i.e., don't keep offering chemo txs that would induce anemia and angina and prompt admissions for r/o MI). He finally concurred, hospice referral was made and she died peacefully at home less than a month later. A colleague (another nurse) who survived breast cancer once commented that when you intentionally poison people for a living you sometime lose sight of things. This definitely applied to my mother's oncologist.

At 7:53 PM, Blogger Scott S. said...

I reject the idea that treatment should be foregone if it has not proven to lead to a prolongation of life.

There are no therapies in chronic lymphocytic leukemia that have been demonstrated to prolong life, yet treatments are given all of the time, because the quality of life is improved dramatically in many cases.

And there is also the off-chance that this latest combination of treatments WILL prolong life.

At 5:02 PM, Anonymous said...

In November my Father will be gone 1 year. He had colon cancer, which spread to the lungs. He never complained much with being in pain. Thank God. It was his anger that scared me. Sometimes when hospitalized he would get angry the nurses would call us up there to calm him down. He didn't even remember that he was at the hospital. Anyway the last week of life. He lay in the bed helpless. I walked over to his bedside the night before he died and told him his granddaughter was there. He opened his eyes stared at her the whole time we were there. When I kissed him good bye he shut his eyes back. The next Morning around 11:30 he was dead. I found him laying there dead, my Mom sitting there just looking at him as she always did. I felt for a pulse in his rist area and his neck, looked at my husband, and he shook his head, like as if to say he is dead. But I couldn't understand one side of him was still warm, the other was cold. It was a horrible experience. I never want to go threw that again, still haven't gotten over it yet. I have been on antidepressants for 2 years now myself. I can't cope. The house Dr. of this hospital was a total jerk, excuse me for saying this but he was. He came in when my Dad was getting worse, and said you know you are going to die. It won't be that much longer now. I wanted to see if he could see someone to help him deal with this. He said no that isn't what he needs. He needs to except it. That's all we can do. I was mad. He never was offered a thing. The oncologists was a pretty good Dr. She never gave up, and took good care of my Dad. So thank you to all, who have a desire to help people like this. It's a hard job. Not many people can do it. Gail

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