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.