Alistair Appleby is an academic GP in the Scottish Highlands with interests in spirituality and health and the philosophy of medical science. He is on Twitter: @DrAlAppleby
Irecently created a twitter poll with the following question “Jean is 81 and is being offered palliative chemotherapy (cost £38,000) which she does not want. She would like to visit her daughter in Australia one last time (Cost £1500), but she cannot afford to. Should Jeanie be given the money?”
Jean is hypothetical, though she is not unlike many of the patients I see in general practice. There was really too little information in the post to answer fully. Would Jeanie be given the £38000, or just £1500? Where would this come from? The implication was that this would come from chemotherapy savings, but that may set precedents.
Recent guidance from the General Medical Council requires doctors to find out what really matters to patients, and make this central to their care.
Some pointed these difficulties out. What would happen about travel insurance? Who would pay for Jean’s care in Australia if she became unwell? Others perhaps tongue in cheek, wanted some “Quality Adjusted Life Years” measures for the “ intervention” of Jeanie’s trip. Despite this 67% of the 49 respondents, doctors and patients among them, indicated “Yes”, Jeanie should be given the money. The proposal remains impractical but the feeling that we should say “yes” suggests discomfort with the fact that Jean’s real priorities are not reflected in the options available to her during her final illness. Recent guidance from the General Medical Council requires doctors to find out what really matters to patients, and make this central to their care.1
Elderly patients still face a dilemma when they attend oncology clinics. During the Covid19 pandemic, they usually have only one person with them and not always their nearest and dearest. As a GP, patients tell me they are asked to make treatment decisions in a few minutes, often in a corridor. In oncology the choices are not straightforward. Treatment might extend life but diminish its quality. There is often a small but real chance that the treatment will kill the patient. Should Jean fight the illness for the sake of Frank, her husband? What would the functional loss from chemotherapy actually mean? If Jean can just about get round the corner to the shop, church or daughter’s house, then chemotherapy, with the inevitable functional stepdown, may seal this option off forever.
Older people have different priorities from their younger selves.
Older people have different priorities from their younger selves, and from each other and most will want to speak to their family. They deserve to be able to sleep on things, speak to a cancer support nurse, their GP or a spiritual advisor. We know that those who have more information tend to choose less care, which in turn saves money for the health service. We take days over deciding which car to buy, would a week be too much for this decision?
Those who have more information tend to choose less care.
I wonder if cancer treatment targets drive this headlong rush, much of the time being eaten up in the wait for the oncology appointment so little time can be offered for decision making. We cannot assume that all those who regret their decision to take chemotherapy have not been consented properly: sometimes a patient may be the unlucky one who does not benefit rather than the nine that do, and we cannot know in which group the patient will fall before the decision is made. However, “enhanced consent” where time, counselling and additional information is available has the promise of reducing treatment regret and treatment costs and, even if this were not the case, simple compassion tells us that all patients deserve treatment that ascertains what is important to them and puts this at the heart of their care.
Pack you bags Jean, your GP is coming with you!
1. GMC: Decision making and consent (guidance effective from 9 November 2020) [cited 2020 Dec 3]. Available from: https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/gmc-decision-making-and-consent-guidance-effective-from-9-november-2020-r3165/