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When You and Your Family Disagree about Treatment

Posted 1/21/2016

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  It should not be surprising that patients and families don't always agree on treatment decisions. Since we don't always agree with our families about other things--ranging from the small questions like which movie to see to the larger ones like how long the in-laws can visit--this seems a likely situation. It can also be a very difficult situation since feelings are running so hot, and the stakes are high.

  Sometimes this comes up with a diagnosis of early cancer when the patient may not want to proceed with chemotherapy. Especially for breast cancer, there are times when the question of adjuvant chemotherapy is not clearcut, and there is a gray area and a place for different conclusions. If pushed, most doctors will offer an opinion, but they also try hard to respect patient choice and to present the information, the options, and then try to stay neutral. Personally, I wish that doctors would more frequently give us their opinion in such situations; they clearly know way more about cancer care than we do, and they are not personally involved, so they can probably think more clearly.

  Hypothetical situation here: Ms. X has a Stage I ER positive breast cancer. The tissue has been sent for an Oncotype test which is a way of determining how responsive the tumor is likely to be to estrogen/hormonal treatment. If the cells are very response, chemo may not be necessary--and, if the cells are not so responsive, chemo is suggested. Sometimes the answer is somewhere in between, and there is a tough call. It is quite common for a woman and her family to have different opinions on whether or not to add chemo to the treatment plan.

  More commonly, family/patient disagreement arises when someone is very ill. In the best situation, patients and their families have been talking about their priorities, their goals, their wishes about end of life. But, again, that has not always happened, and people may feel very differently, and very strongly, either that it is time to stop anti-cancer therapy with all its side effects and concentrate, instead, on quality of life OR that it is always worth pushing forward, no matter what the physical cost, even if there is a 1-2% chance of the drug helping.

  In any of these circumstances, it is very helpful, it is imperative, that a thoughtful, honest conversation ensue, and that everyone tries hard to listen to each other. It often helps to have a third party present; this is something that social workers or chaplains often do, and, of course, doctors are very often part of these discussions.

  My personal view is that the patient always gets the trump vote.

  All of this has been a long introduction to a very nice article from ASCO's CancerNet. Here is the start and a link to read more: 

When You and Your Family Differ on Treatment Choices
A person with cancer may have more than one option for treating the disease, and it may be difficult to choose among them. In making this choice, patients often ask for the opinions of family members. And, in some cases, family members may disagree with each other and with the patient, creating conflict when they need each other's support the most. This is particularly complex when the patient is a child or an adult who is medically unable to make decisions. This article provides suggestions on how to keep the
lines of communication open and work together to make treatment choices.

Guiding principles
If you are involved in selecting treatment, these questions may help you evaluate the choices:
Does the patient understand the risks of treatment and the potential consequences of his or her choices?
Are the patient's wishes openly stated and being respected?
Is this treatment in harmony with the patient's beliefs and values?
In each aspect, the patient's viewpoint is considered first. If you are a person with cancer, you have the right to be heard, the right to state your wishes and have them respected, and the right to change your mind. If you are a family member, remember that the patient has asked for your view because he or she respects your opinion, but various factors may lead him or her to make a different decision. Even when disagreements occur, it is important to keep communicating with each other and to support the patient in his or her choices.
Talk openly about the patient's priorities in undergoing treatment. These could range from surviving as long as possible, regardless of the difficulty of treatment, to maintaining a specific quality of life, even if that means stopping treatment. If this is difficult for your family to discuss, ask as a doctor, nurse, member of the clergy, social worker, or counselor to facilitate this conversation.


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