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January 2014
Scenario: A 60-year-old patient has a large tumor of the floor of the mouth which, in your initial opinion, might be favorably treated with surgical resection and possible radiation therapy. The patient listens to your considerations but declines to entertain any type of treatment. He states he has no close relatives and few friends and can accept his fate.
How can you convince him to have or at least consider potentially definitive therapy? Should you even try to convince him? What are the ethically acceptable courses of action here?—Richard Holt, MD, MPH, University of Texas Health Sciences Center, San Antonio
Discussion
When considering any ethical dilemma involving patients, it is helpful to follow an ethical decision-making paradigm: Obtain additional appropriate information, identify the elements of the dilemma, apply the principles of bioethics appropriately to the situation, and develop a list of ethically acceptable responses.
Often, there is discord among the ethical principles that need to be resolved as part of the decision-making process. In this case, there is friction between what the patient desires (autonomy) and what the otolaryngologist recommends and considers to be in the best interest of the patient (beneficence). In the United States, patient self-determination is the prima facie ethical principle; however, for a patient to make the best medical decision for his condition, the otolaryngologist must be certain that the patient fully understands the implications and potential outcomes of his disease, including pain, bleeding, and disabilities of speech and swallowing.
To ensure the patient is fully informed, he or she should undergo a full oncologic evaluation and staging process. The otolaryngologist should consider that the patient may have concerns or misinformation about the disease and treatment. For example, the patient states: “My neighbor had this cancer and he couldn’t eat or talk after surgery. I don’t want to be mutilated like that.” Understanding such concerns can lead to a frank and empathetic discussion about the realities of his tumor.
Additionally, many patients require more contemplative time than others to reach a healthcare decision appropriate for them. Counseling the patient over a number of visits may be helpful. Additionally, an exploration of the patient’s faith base and his personal definitions of quality of life should be entertained.
If the patient continues to refuse definitive therapy even after being fully informed (evidence-based counseling), the otolaryngologist must now shift to an acceptance of the patient’s decision and provide appropriate supportive care to the patient. Ongoing and early discussions about pain management, airway compromise, and nutrition will prepare the patient for the inevitable future discomfort and disabilities. The issues of mental health support, social support (church, patient support groups), advance directives to physicians, and patient capacity (competence for decision-making) should also be addressed.