CRITICAL THINKING SKILLS. 

"My patients are dying. But it’s their right to keep going"

INTRODUCTION: “Dr. Chan, please, please keep me alive a little longer and God will surely bless you.”

I am watching a 68-year-old man fall apart. He has been through five different types of chemotherapies, yet his kidney cancer continues to grow and metastasize, spreading to different organs. He now sits hunched in his wheelchair. With his worsening diarrhea, and sores in his mouth, he no longer eats with pleasure. Sleeping a few hours without pain has become a luxury.

POSITION- POINT OF VIEW: He wants to beat the cancer. He believes what will help him live longer is more chemotherapy. 

ARGUMENT: Aggressive treatments, such as more chemotherapy, are not going to cure these two patients. Therapy aimed at controlling their symptoms will help them live their remaining days more comfortably. Meanwhile, we still struggle with one of the primary challenges of modern medicine: end-of-life communication.

EXPLANATION: Many physicians encourage early palliative care for terminally ill patients, to make the process of dying less painful, more cost-effective and patient-focused. But if the patients are not ready, instead of feeling relief, they may experience this advice as abandonment. Without first considering how patients understand their own condition, doctors risk returning to a culture of paternalistic medicine, one where physicians make decisions for the patient in the belief that they know best. Disagreements about treatments between doctors and their patients near the end of life can be devastating. So communication is vital.

AGREEMENT: I have been talking to him about palliative care, how focusing on reducing symptoms instead of treating his cancer directly can provide him relief. I even share with him the results of studies showing he could potentially live longer with that strategy

DISAGREEMENT: He believes what will help him live longer is more chemotherapy — so that is what we discuss. (The doctor disagrees that idea).

DESCRIPTION: He now sits hunched in his wheelchair. With his worsening diarrhea, and sores in his mouth, he no longer eats with pleasure.

SUMMARY:  The article describes how difficult is to doctors decide between what are they asked to do in certain situations and what their patients really want. The difference is that doctors know a little more about process or strategies that can help people to feel relief instead of feel pain all the time; on the other hand people think that just with one strategy they can live longer or feel less pain.

Also, the article mentioned a useful strategy to practice with people who suffer of cancer in terms of let them live longer and without too much pain. The article offers some specifics cases about people with cancer and how they deal with this disease.

BACKGROUND INFORMATION:As a young oncologist, I confess I am not an expert in balancing aggressive treatment with preserving quality of life. But it is clear to me that end-of-life care is not checklist medicine. It is not just about statistics or studies. Achieving true shared decisions is an interactive process that takes time and engagement, leading to mutual trust. It is about continuously setting honest expectations for what is possible and making sure all parties truly understand what the consequences are likely to be. Sometimes what our patients need most is just more time: time to accept the terminal diagnosis and time to grieve and hopefully to find peace. Part of our guidance involves agreeing on the personalized therapies, be it “aggressive care” or more symptomatic control,  that can deliver that meaningful extra month, hour or minute.

CONCLUSION: The biggest lesson I have learned is that our role is to support our patients so that they can have the dignity to make these difficult choices and feel empowered to make their own paths, no matter how frightening the decision may be.