|Year : 2021 | Volume
| Issue : 4 | Page : 605-607
Let us give our patients a chance to decide about their treatment: Reiterating patient autonomy
Department of Radiation Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
|Date of Submission||27-Sep-2021|
|Date of Decision||19-Oct-2021|
|Date of Acceptance||20-Oct-2021|
|Date of Web Publication||29-Dec-2021|
Department of Radiation Oncology, Cancer Institute (WIA), Chennai - 600 020, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Iyer P. Let us give our patients a chance to decide about their treatment: Reiterating patient autonomy. Cancer Res Stat Treat 2021;4:605-7
| Personal Narrative|| |
I vividly remember seeing a 73-year-old lady with advanced carcinoma of the left breast. After staging and workup, she was diagnosed with stage III breast cancer. Her son accompanied her. The patient and her son were counseled about the need for treatment to control the growth of her tumor and prevent its further spread. She was offered chemotherapy and referred to a medical oncologist for counseling and management.
After visiting the medical oncologist, who listed the benefits and possible side effects of chemotherapy at her age, the patient and her son opted for only endocrine therapy. Since the patient was experiencing pain in her left breast due to the large tumor size, I advised her to undergo radiation therapy for pain control, as the tablets would take a while to shrink the tumor. However, she refused. Therefore, I referred her to the pain and palliative clinic for pain medications. She was prescribed tablet morphine 5 mg 4 hourly along with appropriate laxatives.
I saw her 3 months, and then 6 months later; during these visits, she had similar complaints with no decrease in the size of the tumor. She was not taking the prescribed opioid analgesics regularly, as advised. Her son said that she felt sleepy after taking the medications, and hence, he gave them to her only in the evening. I once again recommended radiation therapy to reduce the pain and tumor growth, but she was insistent on not having it. She wanted more painkillers and was once again referred to the pain and palliative clinic. Her son was asked to be compliant with the dose of analgesics prescribed. She was asked to take the same dose regularly, with 10 mg morphine at night.
I saw her last month, and she was in intense pain due to fungation of her left breast tumor. That day, I remember the outpatient department was very crowded and I was in a hurry to finish seeing all the patients by 5.00 p.m. When I saw her, it was evident that her cancer had progressed to involve the other breast too, about which she was concerned. She was not receiving an adequate dose of opioid analgesics, as she and her son could not visit the hospital because of the restrictions imposed due to the COVID-19 pandemic. I was upset that she refused to take radiation therapy and chemotherapy, which could have controlled her tumor better. I said, “Now the tumor has become very large, and it is all your fault for not complying with the advised treatment plan.” She asked me worriedly, “Doctor, now my disease has spread to the right breast as well. Can you do something about it? Will I be all right?”
What she needed at that time was empathy and some kind words. Instead, I said that there was not much left to do now. It was then that she told me, “Doctor, please give me a medicine that will help me die.” At that point, I felt sad and angry at her for putting herself and me through this emotional turmoil. I did not say anything, and again sent her to the pain and palliative clinic.
She received care for her malignant wound, and as her pain control was optimum with opioids, she was given tablet morphine 10 mg 4 hourly with a 15 mg dose at night. She was advised to take an extra dose of 10 mg if she experienced breakthrough pain. An adequate dose of laxatives was also prescribed. She had developed a good tolerance to opioids. Her son was counseled regarding the need for giving adequate analgesia to the patient, so that she was comfortable and well rested. He was also given the hospital helpline number for any emergency, in case he could not travel to the hospital.
The lady had left a lasting impact on my mind. I did not know what to do to help her and continued with my consultation. However, deep inside, I was troubled because I knew I had somewhere failed in my duty as a physician.
I had made no effort to find out why she refused the treatment advised by us. I had no idea about her financial and social situation.
Sometimes, in a hurry to finish our work, we fail to look at the patient as a whole and treat only the cancer. I wanted the patient to comply with the advised treatment, and when she was not willing to do so, I felt that she was at fault. I should have looked at the situation from her perspective to understand why she was not willing to undergo an aggressive treatment course. It took a while for me to understand that palliative care should begin from the day of diagnosis and not at the end when the patients are suffering. This was possible through internal reflection of my work; moreover, the palliative care courses helped to further change my perspective. I realized that regardless of the rush and the number of patients waiting to be seen, we cannot hurry through our work to finish at a particular time. Therefore, I have listed below some methods that can help provide holistic care to patients with advanced cancers.
| Physical Care|| |
The patient I mentioned earlier needed good counseling regarding the care required for her local tumor and reassurance that I would do everything to make her comfortable. I should have enquired about her family background and her social issues for a better understanding of her worries and reluctance for treatment. When she came back with a fungating tumor, I should have dressed the wound and prescribed appropriate medications to reduce her pain and treat her infection.
Fortunately, I had the opportunity to meet her once again after a couple of months. This time, I dressed her wound with Metrogyl powder and comforted her by holding her hands and speaking kindly to her. She smiled for the very first time at me. I enquired about her pain, which was well controlled with the prescribed opioid analgesics. I added the oral Metrogyl tablet 400 mg twice a day for 7 days to control the infection. I asked her son about her food intake, bowel habits, and other physical issues, which he told me were well taken care of. I reassured him and taught him to treat the malignant wound with care. He was very pleased and both of them thanked me for my time and patience. I realized that I had not done anything special to relieve her pain or treat her tumor, but the solace they found in my words and the care I offered to her were the only things that really mattered to them.
| Psychosocial Issues and Communication with Family|| |
After enquiring with the son, I learned that he was the sole caregiver for his mother. He was divorced and had no children. He was very dedicated to caring for his mother. He had two brothers who stayed in the same city with their families. He said that they regularly visited their mother, but she would avoid them because of the persistent smell from the tumor despite regular dressings. He would cook food and take care of all the other basic needs for himself and his mother. It would have been difficult for him to see his aged mother going through the side effects of chemotherapy and radiation therapy, and hence, they refused aggressive treatment. It would also have been very difficult for the patient to travel to the hospital daily for radiation therapy. Once I understood these facts, I deeply regretted the way I had spoken to the patient earlier. I was not aware of their psychosocial problems and had been judgmental about them.
| Spiritual Care|| |
The patient was a very simple lady who believed in the doctrine of karma and atonement of past sins. She believed that those who were born were destined to finally die. Some suffer because of past sins. On enquiring about her faith in God, she said that God will take care of all her sufferings. She did not want to be a trouble or burden on her sons in the last few months or years of her life. Hence, I offered her admission to our palliative care hospice for better care and comfort.
| Ethical Issues|| |
Although this patient's autonomy was well respected, it was not well understood by me., Allowing her and her family some more time to explain why she did not want various therapies would have helped me understand their social and financial issues better. The treatment offered would have caused her tumor to shrink and made her more comfortable, but there was a small risk of side effects given her advanced age. Hence, the patient's beneficence and nonmaleficence were kept in mind. When her tumor had progressed beyond the scope of radiation therapy and chemotherapy, she was offered hospice care. The patient will now get admitted to our hospice facility for better care and pain control. Her son has been counseled regarding end-of-life care and other psychosocial issues.
| Policy and Innovations in Practice|| |
I believe palliative care for patients should begin at diagnosis, and training in palliative care must be provided to oncology students early during the course of their studies., Many countries believe in integrating palliative care with standard oncology care to improve patient outcomes and caregiver satisfaction., Our curriculum must focus on including palliative care in oncology training modules and textbooks.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Simha S, Noble S, Chaturvedi SK. Spiritual concerns in Hindu cancer patients undergoing palliative care: A qualitative study. Indian J Palliat Care 2013;19:99-105.
] [Full text]
Taylor RM. Ethical principles and concepts in medicine. Handb Clin Neurol 2013;118:1-9.
Konstantis A. Breaking bad news and autonomy of cancer patients. Cancer Res Stat Treat 2020;3:362. [Full text]
Thomas VM, Mathew A. Truth-telling: Apply the principle of beneficence. Cancer Res Stat Treat 2020;3:359-60. [Full text]
Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al.
American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012;30:880-7.
Asthana S, Bhatia S, Dhoundiyal R, Labani SP, Garg R, Bhatnagar S. Quality of life and needs of the Indian advanced cancer patients receiving palliative care assessment of the quality of life, problems, and needs of the advanced cancer patient receiving palliative care. Cancer Res Stat Treat 2019;2:138-44. [Full text]
Kaasa S, Loge JH, Aapro M, Albreht T, Anderson R, Bruera E, et al.
Integration of oncology and palliative care: A Lancet Oncology Commission. Lancet Oncol 2018;19:e588-653.
Chan KS. Palliative care: The need of the modern era. Hong Kong Med J 2018;24:391-9.