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Hollye Harrington Jacobs

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Making Decisions About Cancer Treatment

Posted: 09/12/11 02:04 PM ET

I find myself at a real crossroads right now with big decisions to make about my treatment for breast cancer. As the end of chemotherapy is on the horizon (which is a wonderful Silver Lining to all of this nonsense), I must make decisions about radiation -- e.g., to do it or not to do it. If I decide to do radiation, I need to figure out where I will do it and how much I will receive?

Rather than make my FBC (F-bomb breast cancer) situation subjective (as my old friend "Chemo Sobby" wants me to do), I need to be fully objective as I take the next steps in creating my plan of care.

One big misnomer, by the way, is that doctors develop a patient's plan of care. No. No. No. Patients have a real responsibility to be fully engaged in the development (and revision) of their own plan of care.

So, in thinking about it "from the other side of the bed," I put on my professional hat (I am a nurse and social worker) and wondered: How would I handle this situation if I were counseling a patient?

The first thing that popped into my head was to utilize a fabulous clinical decision-making tool that I used with patients on a daily basis in my clinical practice. This tool helps demystify clinical decision making by asking objective questions, the answers to which guide the way through the complexity of real cases.

During my Fellowship at the MacLean Center Bioethics Fellow at the University of Chicago, clinical cases were analyzed by using the "Four Box Method" outlined in "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine" by Albert R. Jonsen, Mark Siegler, William J. Winslade.

This Four Box Method provides the framework for understanding how and why to make methodical decisions about health care. Part of this tool includes a list of questions to guide the decision-making process. This is the tool that I referenced when it was time to make my own hard decisions about health care. I simply inserted "me, my or I" when it says "the patient."

Medical Indications (refers to the diagnostic and therapeutic interventions that are appropriate to evaluate and treat a problem):

  • What is the patient's (my) medical problem? DCIS (Ductal Carcinoma In Situ) and IDC (Invasive Ductal Carcinoma). Multifocal T1C (i.e., each of my tumors was less than 2 cm). Grade 2. Negative Margins. Lymphatic/vascular invasion. ER-Positive. HER-2 Negative.

  • What is the prognosis?

  • Is the problem acute? Chronic? Critical? Emergent? Reversible?

  • What are the goals of treatment?

  • What are the probabilities of success?

  • What are the plans in case of therapeutic failure?

  • How can the patient be benefited by medical care, and how can harm be avoided?
  • Patient Preferences (refers to the the choices that a patient makes when faced with decisions about health and medical treatment determined by an assessment of a patient's own values and personal assessment of benefits and burdens of treatment):

    • Based onn a patient's experience, beliefs and values, what does the patient state about preferences for treatment?
    • Quality of Life (Patients and their physicians must determine what quality of life is desirable, how it is to be attained, and what risks and disadvantages are associated with the desired quality.):

      • What sort of life will the patient have during and long after the treatment?

      • What are the risks and benefits associated with quality of life based on the long-term consequences of accepting or refusing a recommendation for medical intervention?

      • What are the prospects, with or without treatment, for a return to normal life?

      • What physical, mental and social deficits is the patient likely to experience if treatment succeeds?

      • Are there biases that might prejudice the provider's evaluation of the patients's quality of life?

      • Is there any plan and rationale to forgo treatment?
      • Contextual Features (Every clinical case is embedded in a larger context of persons, institutions, and financial and social arrangements. The possibilities and the constraints of the context can influence patient care, positively or negatively. Clinical decisions, therefore, may have psychological, emotional, financial, legal, scientific, educational or religious impact on others):

      • Are there family issues that might influence treatment decisions?

      • Are there provider issues that might influence treatment decisions?

      • Are there financial and economic factors?

      • Are there religious or cultural factors?

      • Are there problems of allocation of resources?

      • Is clinical research or teaching involved?

      • Is there any conflict of interest on the part of the providers or institution?
      • I highly recommend using this tool as a starting point and frame of reference for dialogue about the development and revision of a plan for health care.

        It was quite a Silver Lining that my brain worked well enough to be able to apply some of my professional experiences to my own clinical situation (never in a million years would I have thought that I would be doing this!). I'm just grateful that the next steps in my FBC planning process will be thoughtful, analytical and objective.

        Life is the sum of all your choices.
        ~Albert Camus

        To read more about Hollye's holistic and humorous journey over, around, above and below breast cancer, please visit her blog, Brookside Buzz (www.brooksidebuzz.com). You may email her at hollye@brooksidebuzz.com or follow her on Twitter @hollyejacobs.

         

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