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Horns of a Dilemma

From the Department of Medicine, Section of Hematology/Oncology, Medical College of Georgia Cancer Center, Augusta, GA

Corresponding author: Thomas A. Samuel, MD, Medical College of Georgia, 1120 15th St BAA-5407, Augusta, GA 30912; e-mail: tsamuel{at}mcg.edu

INTRODUCTION

Ms J is a 48-year-old woman with a history of metastatic breast cancer who has been observed in the oncology clinic for 8 months. She was initially diagnosed with locally-advanced breast cancer (hormone-insensitive, HER2-neu–negative) in 2004, for which she received adjuvant chemotherapy and radiation. Her cancer subsequently recurred with lung and bone metastases in 2007. At the time of her original diagnosis, she had been treated at a major university oncology clinic. However, when her metastatic disease was discovered, she had a great deal of suspicion regarding her previous care and felt disaffected by her physicians. Thus, she decided to transfer her care to another institution. The new oncologist's impression was that, although she had a rather histrionic personality, she was still able to cope with her new situation and make choices appropriately. Her past medical history was otherwise benign, and there was no evidence of any compromised capacity for decision making.

Unfortunately, at the time of her recurrence, she was noted to have spinal cord impingement requiring emergent radiation therapy. After a course of palliative radiation, she was administered multiple chemotherapeutic agents, none of which induced a response or stabilization of disease. Although she completed two courses of palliative chemotherapy (sequential docetaxel then capecitabine) with few complications, a primary complaint of fatigue did impact her quality of life to the point that she requested a treatment break. Unfortunately, her course on expectant observation was interrupted by the development of brain metastases, for which she completed whole-brain irradiation. However, her disease and radiation left her with residual right-sided weakness, further deteriorating her quality of life. After completing radiation, she returned to the clinic to discuss the reinitiation of systemic therapy because her performance status had sufficiently recovered to consider palliative chemotherapy.

After discussing the merits of third-line chemotherapy in detail, the question to Ms J was whether she wanted to continue on a treatment break or restart therapy. As the query hung in the air with an unpalatable staleness, her silence gave evidence to her struggle in deciding the next course of action. Finally, with deliberate gravity, she said she just did not know what to do. She could not reconcile the low response rate, especially in view of her past experience with cytotoxic therapy, and its associated risk of adverse effects, with her slowly improving but still-limited performance status. She said her quality of life was relatively good, yet she was aware that this would not last long and so she wanted to try something. She just was not ready to make the decision at that point in time. Her oncologist encouraged her that this was reasonable, and that she could take some more time to mull it over as the after-effects of her radiation continued to wear off. She was scheduled to return in several weeks to review her thoughts and her decision regarding restarting treatment.

Three appointments later, over the course of the next 6 weeks, still had not produced a decision. At each appointment, her physicians reviewed the risk of toxicity and the potential benefits of cytotoxic treatment, and each appointment ended the same way: "I’m just not sure." It was made clear to her that not being treated was reasonable or that a drug holiday, especially in view of her difficult course, was also a sound choice. Alternatively, she could choose to start treatment with agents that have a lower risk of adverse effects, such as gemcitabine or vinorelbine. But Ms J would make neither decision. She uncomfortably straddled the fence, with the associated anxiety of an unclear future. Her caregivers sought to involve her family in her care, however her relationship with her immediate family was somewhat strained, for unclear reasons. Therefore, she would not allow her extended family to provide the support she may have needed to arrive at a decision. As a single mother with one young son, her competing hopes were to stay alive as long as possible while remaining as functional as possible for her child's sake, not unlike many patients in a similar situation. Yet, this duality in her mind only further complicated her agonizing decision-making process.

At her last appointment, the oncologist pointed out that by not making a decision, the choice was being made for her, essentially a course of no treatment. It was then that she revealed that worse than her fear of chemotherapy was a far more visceral fear in view of her overall situation: "I just don't want to make the wrong decision."

DISCUSSION

A dilemma is defined as a problem offering two possible solutions, both of which are unacceptable. Formal logic adds a wrinkle to this definition by stating that a dilemma is characterized by two options to a proposed problem that achieve the same ends, so choosing is immaterial regardless of whether the options are comfortable or not. Ms J had found herself caught on the classic "horns of a dilemma." If she chose to be treated, she risked a further decline in her quality of life with no proof of benefit beforehand. The evidence to date in her history supports the likelihood that she would not derive benefit, and in fact, would experience complications related either to her rampant disease or her treatment choice. If she chose not to be treated, she could sustain a quality of life benefit by avoiding the toxicity of therapy; however, this benefit would likely be short-lived and followed by additional decline.

Oncologists often offer patients options and may recommend what they would do if they were in their place. The primary oncologists felt uncomfortable doing this in Ms J's case because one could not be sure which would be the best option for her, as the likelihood of having a poor outcome was high either way. Her history suggested that her disease would likely progress rapidly and lead to further complications. So by their reasoning, either choice could end in the same outcome. So how does one define what Ms J's "wrong decision" would mean in this classic "no-win" situation?

Ms J's concept of a "wrong decision" likely derives from existential angst, a deep-seated condition of insecurity stemming from the awareness of one's own mortality. Although one could describe Ms J as indecisive and vacillating, exacerbated by her noted histrionic personality, the months of aggressive treatment had made her more passive and acutely aware of her impending mortality. Her body had failed her so thoroughly and disappointingly in the past that she could not be sure that any decision made in this setting would restore her. And so she sat on the proverbial fence, uncomfortably allowing time to make the decision for her, rather than settling on a choice that would lead to a potentially unfortunate outcome. Often, patients in this situation may regress to a child-like inability or unwillingness to comprehend the magnitude of the dire issues that face them. Despite an understanding and empathic approach from the physicians involved, patients may be paralyzed by their circumstances due to such regression.

Although this was obviously a difficult position for her, it left her caregivers in a similar position of uncertainty and anxiety about how to proceed. In past years of physician paternalism, one could choose a course under the assumption that "doctor knows best. " In some situations, physicians could explicitly offer patients the option of delegating health care decisions to a family member or to another member of the health care team, even when the patient is not incapacitated. However because of her strained family relations, Ms J's physicians felt conflicted as to how to help her overcome her quandary. How does one support a patient who is competent but unwilling to guide her own management?

Several models and reviews have been developed to address such questions regarding existential pain and anxiety.^1-3 A common approach is to seek guidance in the founding ethics of medical training. The six principles of ethics^4,5 that have guided physicians since medical school are as follows.

1. Nonmaleficence (primum non nocere): first, do no harm.
   
2. Beneficence (salus aegroti suprema lex): a practitioner should seek to act in the best interest of the patient.
   
3. Autonomy (voluntas aegroti suprema lex): the patient has the right to refuse or choose their treatment.
   
4. Justice: one should act with concern for the distribution of scarce health resources in society at large.
   
5. Dignity: the patient (and the person treating the patient) have the right to dignity.
   
6. Integrity: a patient must give informed consent before receiving treatment.
   

Using this construct, one can guide a patient to a choice that addresses the angst of a wrong decision while clearly determining a course of action. For example, if a patient cannot decide whether treatment will help or not, one could err on the side of nonmaleficence and avoid treatment until a patient's dignity justifies an autonomously determined active intervention. If the treatment will have obvious beneficial effects, then these outcomes need to be clearly outlined to the patient through a process of informed consent until the benefits are understood to be outweighed by the risk. Such a process of reasoning with an ethical basis can help to navigate the difficult course of an uncertain future for both physician and patient alike.

To conclude the case report, after several more weeks of hand-wringing, Ms J decided to start therapy with gemcitabine. Her physicians encouraged her that this agent was usually well tolerated and would address her desire to do something about her cancer with the lowest risk of ill effects. She has tolerated her first few treatments well and currently awaits restaging studies to guide her to the next step of care. Though the team acknowledges that they may all be stuck on the horns of the dilemma again soon, one thing that has reassured Ms J is that her physicians will be there with her—to share her angst and to resolve it as best as they all can (patient and caregiver together) with the support of the caregivers’ empathy and her own developing fortitude.

Editor's Note

A commentary on this article follows on pages 2221-2222.

REFERENCES

1. Kelly B, McClement S, Chochinov HM: Measurement of psychological distress in palliative care. Palliat Med 20:779-789, 2006[Abstract/Free Full Text]

2. Morita T, Kawa M, Honke Y, et al: Existential concerns of terminally ill cancer patients receiving specialized palliative care in Japan. Support Care Cancer 12:137-140, 2004[CrossRef][Medline]

3. Block SD: Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: The art of the possible. JAMA 285:2898-2905, 2001[Abstract/Free Full Text]

4. Beauchamp TL, Childress JF: Principles of Biomedical Ethics (ed 5). New York, NY, Oxford University Press, 2001, pp 32-43

5. Brody BA: Life and Death Decision Making. New York, NY, Oxford University Press, 1988, pp 17-48

Submitted October 2, 2007; accepted October 29, 2007.

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Samuel, T. A. Articles by Subbannan, K. Search for Related Content PubMed PubMed Citation Articles by Samuel, T. A. Articles by Subbannan, K. Social Bookmarking                            What's this?