At the end of life, some patients are less capable of making serious decisions than doctors think


End-stage cancer patients have to face difficult decisions: what treatment options should they choose to achieve their goals? When is it reasonable to stop treatment? A study published in The American Journal of Geriatric Psychiatry shows that these patients might be less capable of making these decisions than doctors think.

 

Elissa Kolva, a scientist at the University of Colorado Cancer Centre and Assistant Professor in the University of Colorado Medical Oncology Division, met "patients who did not know why there were in hospital, or who had forgotten or did not know that their cancer was so advanced. However, these patients were still responsible for making major decisions about themselves.”

 

To ensure that the patient is able to make the right decision, Elissa Kolva suggests using four standards: choice, understanding, appreciation and reasoning. The study shows that:

  • 85.7% of patients with advanced cancer were able to express a treatment choice (compared to 100% of healthy adults).
  • 44% of patients, but only 8% of healthy adults, showed poor understanding;
  • 49% of patients, compared to 8% of healthy adults, showed a decrease in their appreciation;
  • 85.4% of patients, compared to 10% of healthy adults, displayed impaired reasoning.

 

It seems important to assess a patient's capacity when he/she is expressing treatment preferences that contradict doctors' recommendations, or when the patient's preferences change dramatically compared to earlier decisions, e.g. when a patient who previously expressed a desire to undergo aggressive treatment then decides to stop therapy.

 

Caution should be exercised when assessing these outcomes, especially when a terminally ill patient requests extreme solutions such as euthanasia or assisted suicide. In such situations, doctors whose care goes beyond that of a service provider responsible for rigidly complying with the requests of a patient whose judgement is altered by his/her condition, play a vital listening and supporting role. This is a physician’s duty of compassion, which is the fundamental purpose of medicine.