How should doctors decide?

John B. monteiro

Extreme medicines are very appropriate for extreme diseases.  – Hippocrates, physician and writer (circa 460 – 375 BC) in whose name modern doctors take their oath.
One of the extreme diseases of today is cancer, generally considered a terminal disease. In treating it, who should decide what is an extreme disease and what extreme medicines are to be given. The obvious answer is the treating or consulting doctor. On further consideration, what about the role of the patient or his/her family? An interesting case has been presented by Dr Jame Abraham, MD, FACP, Bonnie Wells Wilson Distinguished Professor, Chief Oncologist and Medical Director of Mary Babb Randolf Cancer Centre, West Virginia University, USA.  Writing in The Week Health (10-6-12) he gives a case study that analyses the dilemma involved in deciding on treatment for terminal patients. But, first the background.
This is a 36-year-old woman with a recent history of 30-pound weight loss and new onset of blood in the urine....” Dr Peter Simon, one of the junior doctors in the oncology department, was presenting a case before a group of doctors.    
 “The blood test from the referring hospital showed elevated white cells with blasts.”  The patient’s white cell count was more than 3,00,000 when the normal white cell count should be around 10,000. When you see elevated white cells, with immature cells such as blasts, it is a sign of leukaemia, a lethal form of blood cancer.  “Due to the blood in the urine, they did a renal work up which included a It is always fascinating to watch how doctors make decisions. Extremely smart doctors with comparable knowledge can draw totally different conclusions and arrive at entirely diverse decisions. What makes them act so differently? How do doctors think?
 “Without treatment, she will die in the next couple of weeks.” One of the junior doctors turned toward me.
“She may not want to spend the last few days of her life in the hospital. Who wants to do that?” said the radiologist.
“I think we should call the palliative care doctors and make her comfort care,” the general surgeon was visibly upset. That means no active treatment and focusing only on symptom management.
“Have you talked to the patient about the diagnosis and asked her what she wanted?” I asked Peter, who was taking care of the patient.
One of the most striking things I noticed after coming to the US is that doctors here spent enormous amount of time ordering tests and gathering data. Of course, tests and data collection are important for making a diagnosis.
But conversing with the patient and listening to their stories will help us better to come up with an appropriate management plan. Even with the same diagnosis, we may have to treat different patients differently. That is the art of medicine.
“Yes. I talked to her in detail,” Peter paused and looked around. “She does not want to die.” he was skirmish as he completed the sentence.
“Who wants to die? But you cannot change the natural course of a diagnosis,” one of the doctors raised his voice.
“I agree with you, sir. She is a single parent, with a 3-year-old daughter and a 2-year-old son,” Peter continued.
 
“She is a very unfortunate young lady. I don’t think we have an easy decision here. There is no right or wrong answer.” I looked at the medical students.
“In extremely difficult situations like this, I put myself in the patient’s shoes and ponder—what will I do if I am the one lying on that bed....”
The observations and opinions of each doctor in that room may be relevant.
Without discussing the pros and cons of all the options and looking at the risks and benefits, we cannot come up with a treatment plan. But the patient’s values, hopes and dreams must play a major role in making that decision. 
It is very important for patients to understand how doctors think. Doctors are emotional human beings; their decisions are often influenced by a number of factors including their personal bias, prejudice, skills and knowledge.
 doctor whether different specialists will recommend different treatments.”
 After informing and discussing with the patient about the different perspectives of her disease and treatment options, she decided to forgo active treatment. She wanted to spend the final days of her life with her children and not entangled in the complexities of medical procedures. She wanted to sit on her porch and watch her children play.
I will not refute her decisions. It is her life. She has the ultimate say, not the doctors.
The subject is open to many views. What are yours? Over to you.
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