It’s not often that I see a young patient* who doesn’t want any treatment in the immediate aftermath of a cancer diagnosis. In fact, I am so used to making a case for palliative and supportive care that the story of this patient nearly stumped me. The patient’s friends had convinced the patient to come see me as a second opinion because they were concerned that the patient was delaying decision making about treatment. In fact, the patient was even talking about applying for Oregon’s Death with Dignity program for physician assisted suicide and had been discussing this with her primary care physician.
Prior to the cancer, the patient had been very healthy and extremely active. “I’ve had a very good life. I am worried that your documented medical opinion will mess up my decision to go to Oregon to use the Death with Dignity if ultimately, I decide to use this”.
I gave my honest opinion about the prognosis. In this particular case (a rare disease), we just don’t know. Some of our patients do well for many years while others succumb in months and there is no predictive model. I agreed with the treatment plans that had been offered by other physicians. I also offered a potentially less toxic option because the patient seemed more frightened of therapy than the disease. I tried to figure out the reasons underlying the adamant refusal of therapy, but I was unsuccessful. The patient left making me feel like I had not made much of an impression. I wrote my note and sent it to the referring doctors. Then, I started to wonder what the patient had meant about my note messing up the decision related to assisted suicide, so I looked up the Oregon law.Two physicians have to sign that the patient has less than 6 months to live, and that their request is not being made under any type of duress (including psychological). With a nebulous prognosis and an unusual aversion to therapy, my note may indeed have interfered with the patient’s current plan. While in some cases, I wish my patients had access to a program like Oregon’s, cases like this make me scratch my head. I don’t like the idea of using assisted death for existential anguish. Then I ran up against a bigger question: Why exactly is that? What if the patient’s cancer does not progress, but instead suffers is in mental agony for years, unaided by treatment and therapy? Is it really different? I still came up with “yes”, but I don’t know why…do you?
* Note: In order to maintain patient confidential, any identifying details about the case have been altered.
Watch and share this five minute video about the need for prophylactic end-of-life conversations. Laura Heldebrand, an ICU nurse tells her mother's story.
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