Letting the Doctor off the Hook

This is a phrase I’ve coined to help patients talk to their oncologist. As I’ve eluded to in my blog and as another blogger noticed, oncologists continue to treat patients with chemotherapy even if the patient is not a candidate for further treatment. One of the reasons is that they don’t want to take HOPE away from the patient and they are afraid that the patient’s psyche is to fragile to handle the truth. To make matters worse many patients approach chemotherapy as “Please doctor can I have chemo” rather than, “I would like to be treated if in your professional opinion the treatment will increase my time with minimal side effects and risks.” Most doctors will continue to treat, even if contraindicated, if you approach them with the first way of asking the question. I’ve also seen patients that initially wanted treatment (and they said “please treat me”) become angry later after they find out that the treatment wasn’t necessary or produced a poor outcome. I had an experience with a patient that had metastatic colon cancer at age 48, who wanted to live because she had an 8 year old daughter. The oncologist began treating, but this certain oncologist never tells his patients whether the chemotherapy is curative or palliative, and he didn’t tell her that the chemo was palliative only and that her time was limited. The patient had many opportunities to discuss how bad her cancer was but she chose to ignore this and felt that the oncologist would tell her if her cancer was severe. The oncologist never discussed it and it fell on my lap to tell the patient that her chemo was palliative not curative. After our discussion the husband was left to pick up the pieces as the patient didn’t like what I had to say. To make a long story short (2-3 months later), the husband and patient became very, very, very angry with the oncologist because he didn’t fully discuss the patients cancer and prognosis and he prescribed chemo that was perceived not to provide a benefit.  Why do I mention all this…because MOST oncologists will treat any patient as long as the patient is actively seeking treatment. They will even start what we in the field call “chemo-lite.” Which is a chemo agent that will cause the least side effects but make no difference to the cancer except to allow the patient to feel that they are being treated. So how do you let the doctor off the hook? You say something to the effect of, “Doc, in light of my cancer I only want to discuss treatment options that will potentially benefit me, but I’m ok not receiving any treatment if you do not expect treatment to be beneficial for me.” By approaching treatment this way, you give the doctor some breathing room and a chance to say, “you know chemo may not be beneficial for you with this type or stage of cancer.” If you approach the doctor with resting all your HOPE on chemo/treatment, then guess what, there will always be chemo available to you. However, if you initiate conversations about and put more importance on quality of life, dignity and spending time with family and friends with your remaining time, you are less likely to get unnecessary treatments and more likely to have a better death. In fact when some patients opt for further unecessary treatment, they can potentially shorten their life. This seems conterintuative since the whole reason they are receiving chemo is to lengthen their life. Please email me for further advice about how to discuss sensitive issues with your doctors.

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4 thoughts on “Letting the Doctor off the Hook

  1. The problem is that in our medical culture, THERE IS ALWAYS SOMETHING WE CAN DO ! The question is SHOULD we be DOING SOMETHING ? And should the something that we are doing, be directed at QUALITY of life or QUANTITY ? We all know that it is not for us the medical community to decide what is quality of life for anyone besides ourselves. That being said, MD’s should offer up the discussion about more treatment to extend life with side effects, vs stopping treatment with the potential of not extending life, but having the amount of time left, free of hospitalizations, free of stomatitis, nausea, vomiting, fatigue. Also physicians should not let patients direct their care. Is it even fair to the lay person to be given the burden of making decisions regarding that which they have no expertise ? We the medical professionals should be telling patients when it is futile, not “trying one more treatment.” In this country we are so afraid of death, that we look for anything and everything to prolong life. It is like when a pt presents to the ER with Dyspnea, the ER doc says “Would you like me to put a tube down your throat so you can breathe ?” Who in their right mind would say “no let me suffer “? They never discuss options, “Look you have end stage (cancer, copd, ) we can keep you comfortable with some medication, because you might end up being on life support for the rest of your life. We talk alot about informed consent but are we really informing our pts of their options ?

  2. I’m going to take the cynical approach to this discussion and throw out a comment about incentive. Oncologists are incented by huge amounts of money to treat everything and anything with chemo. If a patient or family desires treatment to be given, even if it is futile, the physician has no solid reason to argue. I wonder if practice patterns would change if Oncologists were not allowed to make any money from pharmaceuticals. My understanding is that nearly half of the Oncologists’ income is from selling pharmaceutical agents – it would be interesting if somebody published something about the impact of that on treatment practices.

  3. Putting myself in the patient’s shoes, I cannot even imagine how much hope, hope that she was getting better, better to see her eight year old daughter grow up, better to be around her family and friends only to find out that the treatment she was receiving was palliative and not curative. The patient and family lost so much precious time to plan out the rest of her days. It is absolutely terrible that it fell on you to tell this to the patient. I cannot even imagine what both and her husband went through at that given moment. It is heartbreaking. I never even heard about, “chemo-lite” till I read your blog. Is that even ethical? Makes me wonder if that is what my grandfather received. Great post once again and just want to let you know reading each and every post of yours tugs at my heart. Your patients are extremely blessed to have a physician as caring and compassionate as you are

    • Sarah, thank you for your thoughts. I think most physicians would agree that “Chemo-lite” is not ethical, yet it is done more frequently than most people realize. That is why it is so important to “let the doctor off the hook,” although physicians shouldn’t be offering any intervention which is not appropriate both for cancer and non-cancer patients.

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