The Physician on the Horns of a Dilemma
Authors: Charles L. Loprinzi, Gregory P. Kalemkerian
Journal: Journal of Clinical Oncology (2008)

In the essay, “Horns of a Dilemma,” Samuel and Subbannan discuss a challenge many of our patients face when confronted with therapeutic options, particularly when none of the available options offer the chance for cure. This is a common situation in the practice of oncology, and one that is becoming more frequent as we develop a broader array of therapeutic options for many malignancies. As occurred in the vignette presented in the essay, the physician’s own discomfort in making a recommendation regarding additional care can exacerbate the dilemma by placing too much of the decision-making burden on a patient who may not be emotionally or psychologically capable of making such choices. Even in our current era of patient autonomy, it is unfair to place the entire burden of decision making on the patient. After presenting the reasonable and acceptable management options, in patients who do not seem to be comfortable making a decision, the physician should make a clear recommendation and share it in a manner that allows the patient to either agree with the decision or gracefully chose an alternative option. Frequently, the physician’s recommendation will serve as a catalyst that clarifies the patient’s own desires and moves the clinical plan forward. Before making a recommendation, physicians need to ensure that their patients understand the goals of care and the potential benefits and risks of each management option. This applies to both the treatment options and the no-treatment option. For example, in a situation like the one in the essay, the physician can unambiguously state that cure is not a realistic goal and that the proposed therapeutic options are usually of limited benefit. Physicians should also acknowledge that there is always some degree of uncertainty in medical prognostication, and that this uncertainty can complicate therapeutic decision making. They should then provide relatively specific information regarding the potential benefits and risks of each clinical option. The benefits should be discussed in terms that the patient can understand, such as probabilities for tumor shrinkage or control, or potential increases in 1-year survival rates. If a particular treatment could prolong survival time, the physician should provide an estimate of whether this prolongation of survival is usually measured in days, weeks, months, or years. Realistic information on the potential risks of additional therapy should also be discussed, taking into account the individual patient’s prior experiences and current performance status. The provision of all of this information will frequently help patients determine their level of interest in pursuing additional therapy. If, however, a patient remains reluctant to voice an opinion regarding his or her care, the physician can offer additional guidance by relating that, given this information, some patients would choose to receive chemotherapy, whereas others would not. The patient should be assured that there is no right answer for all patients in the current situation. It can be helpful to provide a continuum story to illustrate the range in how patients think about therapeutic options. The two ends of the continuum can be illustrated by noting that some patients will opt for supportive care with statements such as, “I’m tired of shots and medicines unless they are really, really good,” whereas others will want additional treatment regardless of high risks and marginal benefits, stating, “I need keep fighting, to be as aggressive as possible.” Patients can then sort through their own feelings toward additional therapy by determining where they fall on this continuum, allowing them to make a decision with which they are comfortable. Importantly, the physician should then fully support whichever decision the patient makes, while also acknowledging that all medical care is dynamic and that the patient has the option of changing their decision in the future. Despite this exercise, some patients will still be unable to make a decision. Given this situation, it may be best for the physician to relieve the burden of decision making from the patient by making a firm recommendation as to the course of additional care. To some, this will seem excessively paternalistic—a throwback to the role played by physicians several decades ago when they routinely made management decisions with minimal patient input. However, it is a role which physicians must be willing to accept. We are still the medical professionals in the relationship, the ones with the training and expertise to sort JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 13 MAY 1 2008