Get your patient involved in treatment decision-making

Ethics Forum. March 3, 2003.

Scenario: How should you answer the "What would you do" question?

An elderly patient gets a diagnosis of prostate cancer. After the doctor has given the risks, benefits and likely consequences of treatment options (including nontreatment), the patient asks, "What would you do if you were in my shoes?" Should the doctor answer this question without paternalistically directing the patient's decision?

Reply:

A patient with prostate cancer is faced with a choice between watchful waiting and radical prostatectomy. Surgery presents the best chance for a cure, but it also carries significant risks for postoperative complications, including incontinence, impotence, infection and pain. Watchful waiting avoids these risks, but carries a slightly increased chance of death from cancer and causes some patients to worry about whether they should have treated their cancer more aggressively.

Only this elderly patient can decide whether he prefers the risk of incontinence and impotence over lingering concerns of cancer spread. Yet the patient responds to the information and choices he is given by asking the physician how she would approach such a decision. The physician is faced with a dilemma: She wants the patient to make a choice that fits his values, but at the same time, she does not want to ignore her patient's request for a recommendation.

Physicians are increasingly aware of the importance of patients' values in health care decision-making -- recognizing that the "correct" choice often depends on what a specific patient feels about risks and benefits. When patients participate in medical decisions, they are more satisfied with their medical care, more adherent to medical regimens and experience greater psychological well-being and health. But how should physicians involve patients in such decisions?