Do We Always Need to Tell Patients the Truth?

There are some very sane oncologists, but they are rare birds. Dr. Simone M.Ms., M.D., one of the sanest, speaks a volume of truth in the following essay:

DO WE ALWAYS NEED TO TELL PATIENTS THE TRUTH?

In my experience, cancer patients who receive treatment know their situation. Even very young people know. A six-year-old boy who I was treating for leukemia at the National Cancer Institute asked me what it was like in heaven. A national survey found that 96% of Americans wanted to be told if they had cancer and 85% wanted to know how long they would live if their [type of] cancer usually led to death in less than a year.

Moreover, a legal case involving ethical informed consent (Arato v. Avedon) asked whether the law should force physicians to report statistical life expectancy information to patients. Mr. Arato had pancreas cancer that was treated surgically, then with experimental chemotherapy and radiation because there “is no effective treatment.” The surgeon and oncologist never told Mr. Arato and his wife that only 5% survive for 5 years, nor did they give a prognosis or estimate of his life expectancy, nor were they asked. A recurrence occurred and the physicians knew he would die within a few months but did not tell the patient about life expectancy.

The patient died and his wife sued the physicians claiming that the doctors were obligated under California’s informed consent law to tell the patient about survival figures before asking him to consent to chemotherapy. The court decided Mr. Arato should have been informed. The physicians said if the patient knew of the high mortality rate, he would have no hope. And during the 70 visits, the patient did not ask questions about his life expectancy indicating to the physicians that he did not want to know. The patient’s wife said had the patient known the facts, he would have declined all treatment and attended to his business affairs. His wife incurred tax losses due to poor business planning.

The lower court favored the physicians. The appeal court reversed the decision. The California Supreme Court upheld the decision in favor of the wife because of the doctrine of informed consent based on four tenets:

1. Patients are generally ignorant of medicine.
2. Patients have a right to control their own bodies and thus to decide about medical treatment.
3. To be effective, consent to medical treatment must be informed.
4. Patients are dependent upon their physicians for truthful information and must trust them (making the doctor-patient relationship a “fiduciary” or trust relationship rather than an arm’s length business relationship).

The court concluded “the physician is under a legal duty to disclose all material information—information regarded as significant by a reasonable person in the person’s position when deciding to accept or reject a recommended medical procedure—needed to make an informed decision regarding a proposed treatment.”

The practice of medicine is an art as well as a science. It involves compassion and honesty. A good physician will always give a ray of hope as well as discuss the implications of a grave situation.

It is often easier to give another round of ineffective chemotherapy than to tell patients that there is nothing left in the anti-cancer arsenal. The clinician should sit with patients and families, hold their hands and tell them there is no way to control their cancer, but they will not be abandoned and will be made as comfortable as possible.

Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge,by Robert M. Veatch,[1] makes two main points: Patients alone are in charge, and they have no choice but to assume this active role. According to this “manifesto,” “doctors will no longer be seen as capable of determining what will benefit their patients. It is patients themselves who, in the world of the new medicine, have to take charge.”

Veatch starts from the assertion that “literally every medical choice—no matter how mundane—inevitably requires value judgments,” and says that, “physicians make them only by imposing their personal and often idiosyncratic views on their patients. From this premise flows a host of startling conclusions. Hospice care is too value-laden to be covered by health insurance. Physicians “will no longer ‘certify medical necessity,’ or even recommend any treatment, let alone give ‘orders’ or claim they know what is best for the patient.”

Instead, doctors will merely document a patient’s diagnosis, leaving patients to decide (in consultation with pharmacists) whether to medicate and which approved drug and dosage to take. Veatch sheds light on a fundamental change sweeping through the American health care system, a change that puts the patient in charge of treatment to an unprecedented extent. The change is in how we think about medical decision-making.

Modern Medicine in Trouble

Contemporary medicine has other looming problems because of a shortage of physicians who are interested and capable of administering basic care. Dr. Nisha Nathan wrote, “One suggestion is that non-physician medical professionals, such as nurse practitioners and physician assistants, can pick up the slack. Doctors, however, said this may not be enough to fill the gap. Another potential solution is patient-centered homes, where everyone works on a team in effort to increase the number of patients per provider. Some patients can be served by a computer online portal or a phone encounter when feasible to decrease the number of physician visits. Most experts encourage consumers to challenge the current system, hold political leaders accountable, insist that government officials demand change in health care system design, policy, and reimbursement, along with medical school admissions and residency position allocations.”

In Greece and Spain government-sponsored medicine is already collapsing as bills go unpaid. Governments are not even paying basic pharmacy bills and pharmaceutical companies are cutting off supplies because hundreds of millions are owed.

In the United States it’s another story. In 2011, prompted by emotional pleas by cancer patients and others who said the drug shortage was threatening lives, President Obama issued an executive order requiring drug makers to notify the F.D.A. when a shortage appeared imminent. Sterile injectable drugs account for about 80% of the scarce medicines; this is crippling mainstream medicine’s ability to take care of people.

In 2011, 251 drugs were declared in short supply. This year, slightly more than 100 were placed on the list, and workers say the battle to keep pharmacy shelves stocked continues unabated. The list of hard-to-find medicines ranges from basic drugs like the heart medicine nitroglycerin to a lidocaine injection, which is used to numb tissue before surgery.

2012-11-19 17:00:55

Source: http://blog.imva.info/medicine/patients-truth/?utm_source=rss&utm_medium=rss&utm_campaign=patients-truth