Tough decisions

Dr. Jeffery Parks is a board certified general surgeon working in Cleveland who writes regularly at Buckeye Surgeon.

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Sometimes our medical oncologists will us ask us to place Mediports on their patients ASAP so that chemotherapy can be started promptly. A lot of times my office will just add the patient onto the day’s OR schedule and I’ll meet the patient for the first time an hour or two prior to the procedure to discuss things. The other day I picked up the chart of a lady who needed a port and the first thing I noticed was that she was 92 years old. I must admit, my first thought was: what the hell are we doing here? She had metastatic breast cancer with lesions seen in her lungs and liver. I was all ready to march into the room and have an honest, heart to heart talk with the patient and the family about futile care and cost effectiveness etc etc.

But I composed myself. Every situation is different. I asked questions. I listened. Her breast cancer had been treated 15 years ago. This was an unusually late recurrence of disease. And the patient sure as hell didn’t look like the typical 90 year old I know. She was robust and charming and full of zest. She was one of those old ladies who are always winking at you at the end of sentences. She kept telling me that I’d better not screw up the procedure. Her daughter sat next to her and smiled supportively.

I asked her if Dr X. had gone over the side effects of the proposed chemotherapy. She said yes. She understood it was not going to be easy. But she was ready to endure it. She had two grandchildren who hadn’t gotten married yet. Anything to give her just a little more time. She winked again.

Dr X. is a respected oncologist in our community. She had been seeing him for over 10 years. He is an employed Cleveland Clinic doc, so he wasn’t going to make any more money based on whether she chose chemotherapy or not. Assuredly this had been a difficult decision for him, recommending such an aggressive course. I was just meeting this woman for the first time. Who was I to presume to dictate to her what was reasonable? She had a long-standing relationship with a physician who undoubtedly was very honest with her about her options. The decision they made, it really wasn’t any of my business. The port went in uneventfully.

These are the scenarios we see all the time in the real-world practice of medicine. It isn’t always cookbook easy. But who do we want making these sorts of tough decisions: doctors/patients or some faceless bureaucracy in Washington DC that mindlessly follows an arbitrary algorithm? Legitimate arguments can be made for both sides…

[Front page Flickr photo courtesy of Shutr]