Quite an interesting discussion. My sister had breast cancer did all the chemo and radiation despite considerable lymph involvement. She got 15 more years of good life but bone cancer arrived. I had just finished chemo as a adjuvant to an aggressive colon cancer which was debilitating at age 72. She was much younger but decided against any more chemo trusting in nutritionals. I fully understood the toll that chemo takes and was happy for her decision. She then made it another year with a lot of decline. She was able to work for most of that year. I suspect that at 82 I might choose the same option given a return of cancer depending on how my oncologist frames treatment. Using Xeloda and later Folfox did take a toll but maybe there could be less harsh methods. OTOH I have had a fine life so am perfectly OK with hospice should that be needed.
Great article! I read Thinking Fast and Slow, in residency, and it changed my mind, on how we are so systematically biased in our judgements/decisions subconsciously. Loss Aversion and Sunk cost fallacy, and the whole array of cognitive biases, really made me aware of my own flaws, but pretty much questioned every decision I made afterwards. Trust but verify, was the tenet. I wish, this book could be taught in medical school, and as part of a healthy discussion, on challenging or questioning decisions being made by either a specialist/attending or a medical student. Doctors, and their egos, prevent them from being self aware of their own biases. Critical appraisal is essential, and needs to be ingrained as a skill, early on, before the student enters the unfortunate hierarchy, where he must never dare to question. Radical change in the culture is essential to allow a healthy environment of curiosity, and challenge.
On point, thank you Dr. Chakraborty. As a general internist over the years, I had many occasions to question the wisdom of aggressive therapeutic interventions unlikely to benefit patients near the end of life, not just cancer but heart disease, neurodegenerative disorders along with frailty and advanced age. These are tough decisions, maybe the toughest for patients, but we often fail to help our patients adequately weigh the pros and cons just as you explain. It's common, as we all know.
An extreme example. I had a 98 year old gentleman present with a nearly completely obstructing advanced aggressive unresectable cancer of the distal rectum and anal canal. I met with the patient and his wife, recommended a diverting colostomy followed by palliative care, a plan of care shared by his gastroenterologist who had made the diagnosis. The colorectal surgeon to whom he was referred disagreed and referred the patient to a radiation oncologist who recommended a course of radiation therapy. While in the hospital, on day two of his XRT, his colon perforated, he became septic and died.
I had a cardiologist colleague who once when we were discussing a chronically ill mutual patient who had died following a high risk intervention, a decision that in retrospect he questioned, commented, "we killed him so he wouldn't die." We are all, patients, loved ones, physicians, subject to heuristics that bias our better judgement.
I have a feeling RNs will be doing a lot of responding to this dilemma as we are usually the second line of information gathering and giving.
As a hospice nurse I face this every day practically and here is how I handle it:
1 - I come behind a doctor who has given information about EOL, treatment vs comfort. My patients are always shocked when I tell them they have less time than they thought they had. Whether it's what the doctor said or more probably what the patient and family heard, I've had to have that tough conversation about the reality of time left.
2 - When I need to review treatments, medications, choices, etc I begin by saying it's my job to be there with my knowledge to explain what they don't understand. I lay all the cards on the table face up showing the pros and cons, ups and downs, the good and the ugly. I also tell them that there is no bad choice because the choice they make will be right for them at that moment. This choice would be wrong if they didn't look at it from all sides.
3 - I've witnessed dozens of times patients and families choosing what I would deem a horrible decision. But it's not my life. I've never walked in their shoes. I would become angry (why are they being so silly?), hurt (I am a good nurse, they should believe in me), frustrated (did I not explain things well enough?)
There is only one response to this entire scenario and that is we are not in control. There is a higher power, God, whatever you wish to call Him/Her, and that entity will direct their way. I can only do what I do best and do it well. I meet them where they are. I walk beside them for the rest of their journey. At each juncture I am there with my education to teach them what their choices at that moment.
Finally - in my own experience - my husband of 33 years @ age of 61 was diagnosed with Stage IV non-small cell lung CA. During a visit to the pulmonologist, knowing what my career was, tried to tell my husband that surgery was an option. My husband at that time had lost 30 lbs, slept a lot, his brain was fuzzy, and was having severe GI symptoms. We went to him so that I could know I had crossed all my Ts and dotted my Is. We went home and he signed up for hospice. [Dr X, Pulmonologist, please tell my husband the reality of the situation.]
Vinay will not, just cannot, bring himself to proofread any of his stream-of-consciousness stuff once he gets the keyboard and gets it spraying out the words. RE: . . . . .in the present post we find "YIELDS power". Vinay, it is "Wields power....". Jesus, don't you ever wonder whether a sloppy presentation of self might sooner or blunt your otherwise regularly useful impact? What other details in your modus operandi are you habitually careless about?
Such an important topic to be discussed. As a RN I learned from personal experience many years ago something about this very dilemma. My dear friend, 50 yrs old at the time, was diagnosed with a GBM. Being a nurse herself, she asked that I be her eyes and ears and do the research. It was a 19 month marathon, that's for sure. In the end, she was not well advised by her medical team when the treatments stopped working. You see, she was 50 and so they continued to do everything possible to keep her alive. I've never been so disillusioned in the medical profession. I kept saying to them, she is dying, let her go. Only one physician listened to me, the family practice doc. He finally stopped the treatments and she died a few weeks later.
What it taught me was that the dying can teach us how to live. When the time came and my parents were diagnosed at the ripe ages of 89 and 85 with CA, they turned to me as what course to take. They were both very healthy and lived independently. Chemo or palliative care? It was an easy decision. Spend the time you have left, reasonably well, surrounded by loved ones, in your own home. I've never looked back.
Quite an interesting discussion. My sister had breast cancer did all the chemo and radiation despite considerable lymph involvement. She got 15 more years of good life but bone cancer arrived. I had just finished chemo as a adjuvant to an aggressive colon cancer which was debilitating at age 72. She was much younger but decided against any more chemo trusting in nutritionals. I fully understood the toll that chemo takes and was happy for her decision. She then made it another year with a lot of decline. She was able to work for most of that year. I suspect that at 82 I might choose the same option given a return of cancer depending on how my oncologist frames treatment. Using Xeloda and later Folfox did take a toll but maybe there could be less harsh methods. OTOH I have had a fine life so am perfectly OK with hospice should that be needed.
Great article! I read Thinking Fast and Slow, in residency, and it changed my mind, on how we are so systematically biased in our judgements/decisions subconsciously. Loss Aversion and Sunk cost fallacy, and the whole array of cognitive biases, really made me aware of my own flaws, but pretty much questioned every decision I made afterwards. Trust but verify, was the tenet. I wish, this book could be taught in medical school, and as part of a healthy discussion, on challenging or questioning decisions being made by either a specialist/attending or a medical student. Doctors, and their egos, prevent them from being self aware of their own biases. Critical appraisal is essential, and needs to be ingrained as a skill, early on, before the student enters the unfortunate hierarchy, where he must never dare to question. Radical change in the culture is essential to allow a healthy environment of curiosity, and challenge.
Very nice and deep essay from Dr Rajshekhar Chakraborty, illustrating the importance on how we frame medical information...
And also showing that the "doctor" is as human as the "patient"...
Thank you Raj !
On point, thank you Dr. Chakraborty. As a general internist over the years, I had many occasions to question the wisdom of aggressive therapeutic interventions unlikely to benefit patients near the end of life, not just cancer but heart disease, neurodegenerative disorders along with frailty and advanced age. These are tough decisions, maybe the toughest for patients, but we often fail to help our patients adequately weigh the pros and cons just as you explain. It's common, as we all know.
An extreme example. I had a 98 year old gentleman present with a nearly completely obstructing advanced aggressive unresectable cancer of the distal rectum and anal canal. I met with the patient and his wife, recommended a diverting colostomy followed by palliative care, a plan of care shared by his gastroenterologist who had made the diagnosis. The colorectal surgeon to whom he was referred disagreed and referred the patient to a radiation oncologist who recommended a course of radiation therapy. While in the hospital, on day two of his XRT, his colon perforated, he became septic and died.
I had a cardiologist colleague who once when we were discussing a chronically ill mutual patient who had died following a high risk intervention, a decision that in retrospect he questioned, commented, "we killed him so he wouldn't die." We are all, patients, loved ones, physicians, subject to heuristics that bias our better judgement.
I have a feeling RNs will be doing a lot of responding to this dilemma as we are usually the second line of information gathering and giving.
As a hospice nurse I face this every day practically and here is how I handle it:
1 - I come behind a doctor who has given information about EOL, treatment vs comfort. My patients are always shocked when I tell them they have less time than they thought they had. Whether it's what the doctor said or more probably what the patient and family heard, I've had to have that tough conversation about the reality of time left.
2 - When I need to review treatments, medications, choices, etc I begin by saying it's my job to be there with my knowledge to explain what they don't understand. I lay all the cards on the table face up showing the pros and cons, ups and downs, the good and the ugly. I also tell them that there is no bad choice because the choice they make will be right for them at that moment. This choice would be wrong if they didn't look at it from all sides.
3 - I've witnessed dozens of times patients and families choosing what I would deem a horrible decision. But it's not my life. I've never walked in their shoes. I would become angry (why are they being so silly?), hurt (I am a good nurse, they should believe in me), frustrated (did I not explain things well enough?)
There is only one response to this entire scenario and that is we are not in control. There is a higher power, God, whatever you wish to call Him/Her, and that entity will direct their way. I can only do what I do best and do it well. I meet them where they are. I walk beside them for the rest of their journey. At each juncture I am there with my education to teach them what their choices at that moment.
Finally - in my own experience - my husband of 33 years @ age of 61 was diagnosed with Stage IV non-small cell lung CA. During a visit to the pulmonologist, knowing what my career was, tried to tell my husband that surgery was an option. My husband at that time had lost 30 lbs, slept a lot, his brain was fuzzy, and was having severe GI symptoms. We went to him so that I could know I had crossed all my Ts and dotted my Is. We went home and he signed up for hospice. [Dr X, Pulmonologist, please tell my husband the reality of the situation.]
Moving article. Thank you.
Vinay will not, just cannot, bring himself to proofread any of his stream-of-consciousness stuff once he gets the keyboard and gets it spraying out the words. RE: . . . . .in the present post we find "YIELDS power". Vinay, it is "Wields power....". Jesus, don't you ever wonder whether a sloppy presentation of self might sooner or blunt your otherwise regularly useful impact? What other details in your modus operandi are you habitually careless about?
Such an important topic to be discussed. As a RN I learned from personal experience many years ago something about this very dilemma. My dear friend, 50 yrs old at the time, was diagnosed with a GBM. Being a nurse herself, she asked that I be her eyes and ears and do the research. It was a 19 month marathon, that's for sure. In the end, she was not well advised by her medical team when the treatments stopped working. You see, she was 50 and so they continued to do everything possible to keep her alive. I've never been so disillusioned in the medical profession. I kept saying to them, she is dying, let her go. Only one physician listened to me, the family practice doc. He finally stopped the treatments and she died a few weeks later.
What it taught me was that the dying can teach us how to live. When the time came and my parents were diagnosed at the ripe ages of 89 and 85 with CA, they turned to me as what course to take. They were both very healthy and lived independently. Chemo or palliative care? It was an easy decision. Spend the time you have left, reasonably well, surrounded by loved ones, in your own home. I've never looked back.
Thanks for your article.