1 00:00:06,550 --> 00:00:09,56 Mike Andrews had a very difficult decision to make. 2 00:00:09,56 --> 00:00:11,770 He was a patient of mine in the hospital who had been admitted with acute 3 00:00:11,770 --> 00:00:14,622 leukemia, that meant his white blood cells had turned into cancer and were 4 00:00:14,622 --> 00:00:19,86 threatening to end his life. In fact, there was not doubt his life was 5 00:00:19,86 --> 00:00:22,20 not going to be A very long one at this point. 6 00:00:22,20 --> 00:00:26,212 We was in his mid 50s and he had a few days, weeks, maybe months to live. 7 00:00:26,212 --> 00:00:30,500 He would either die of leukemia or of the treatment for leukemia, and therein lay 8 00:00:30,500 --> 00:00:33,540 his choice. He had to decide whether to take 9 00:00:33,540 --> 00:00:36,740 chemotherapy that had the potential to extend his life but not cure him of the 10 00:00:36,740 --> 00:00:40,426 leukemia... But was definitely going to make him 11 00:00:40,426 --> 00:00:44,330 miserable in the process. And might even shorten his life. 12 00:00:44,330 --> 00:00:45,710 So he had this difficult decision to make. 13 00:00:45,710 --> 00:00:48,550 I'm Peter Ubel. I'm a physician at Duke University. 14 00:00:48,550 --> 00:00:51,420 I tell Andrew's story in my book, Critical Decisions. 15 00:00:51,420 --> 00:00:54,128 I wanted to tell you now. Are some of the ways that medical 16 00:00:54,128 --> 00:00:57,340 decisions differ from other decisions we face in life. 17 00:00:57,340 --> 00:01:01,45 I will use Andrews' story as part of the way to get into this really fascinating 18 00:01:01,45 --> 00:01:04,636 topic of how medical decisions raise questions and issues and unconscious 19 00:01:04,636 --> 00:01:11,80 irrational forces that aren't necessarily there in other decisions we face in life. 20 00:01:11,80 --> 00:01:14,934 So, Andrews had this choice. Does he take chemotherapy, at the risk of 21 00:01:14,934 --> 00:01:17,880 shortening his life and making himself miserable? 22 00:01:17,880 --> 00:01:20,625 Or does he just get comfort care to relieve the pain and suffering from his 23 00:01:20,625 --> 00:01:23,640 leukemia and live the last few months of his life without going through terrible 24 00:01:23,640 --> 00:01:27,345 treatments? Before he can make that decision, though, 25 00:01:27,345 --> 00:01:32,590 he needed 1 more piece of information. He needed to know the odds would, would 26 00:01:32,590 --> 00:01:37,501 respond to the chemotherapy. And that depended on the results of 27 00:01:37,501 --> 00:01:42,582 genetic testings of his leukemia. The test results came back and I met with 28 00:01:42,582 --> 00:01:46,540 the oncologists, the cancer doctors, outside Mr. 29 00:01:46,540 --> 00:01:49,298 Andrews' room to talk about the results and they weren't good. 30 00:01:49,298 --> 00:01:52,558 The oncologists looked me in the eye and said it's bad news. 31 00:01:52,558 --> 00:01:56,782 At best, there's a 5% chance his leukemia will respond to the treatment. 32 00:01:56,782 --> 00:01:59,718 Terrible news. So we went to the bedside. 33 00:01:59,718 --> 00:02:03,55 The oncologist sat down next to Mr. Andrews and explained what chemotherapy 34 00:02:03,55 --> 00:02:06,268 would entail, the fact that he wouldn't be cured no matter what happened, et 35 00:02:06,268 --> 00:02:09,250 cetera. Andrews understood this all. 36 00:02:09,250 --> 00:02:13,282 He said but doc, I want to know what are the odds that my cancer will respond to 37 00:02:13,282 --> 00:02:17,526 the chemotherapy? The oncologist took a deep breath and 38 00:02:17,526 --> 00:02:21,430 said 20%, Mr. Andrews, 20% chance that you'll respond. 39 00:02:21,430 --> 00:02:24,150 He said well those are fighting odds. Let's go for it. 40 00:02:24,150 --> 00:02:28,970 We left the room and the oncologist signed the orders for the chemotherapy. 41 00:02:28,970 --> 00:02:30,856 What happened here? Well I'm going to get to his story a 42 00:02:30,856 --> 00:02:33,754 little bit more but let me tell you about just a number of factors that went in 43 00:02:33,754 --> 00:02:37,740 here. That's, that highlight how weird medical 44 00:02:37,740 --> 00:02:40,716 decision can be, medical decision making can be. 45 00:02:40,716 --> 00:02:44,610 It starts with the fact that we're often asking patients to make decisions that 46 00:02:44,610 --> 00:02:48,209 are unlike any decisions they faced in their lives, and that force them to 47 00:02:48,209 --> 00:02:53,220 imagine the unimaginable, to predict the unpredictable. 48 00:02:53,220 --> 00:02:56,405 To imagine what it's like to experience something they've never experienced 49 00:02:56,405 --> 00:03:00,20 before. In fact in Mr Andrews case that began 50 00:03:00,20 --> 00:03:04,850 with the bone marrow biopsy we used to diagnose him with leukemia. 51 00:03:04,850 --> 00:03:07,190 A bone marrow biopsy and I sorry to have to describe this to you even, it's 52 00:03:07,190 --> 00:03:11,151 painful even to just here about it. It involves taking a needle about the 53 00:03:11,151 --> 00:03:15,55 size of my pinky, and burring it into a person's hip bone which we try to numb up 54 00:03:15,55 --> 00:03:20,410 with medicine, but frankly we never can cover up all the pain. 55 00:03:20,410 --> 00:03:23,875 And in Andrew's case, was the most painful thing he said he'd experienced in 56 00:03:23,875 --> 00:03:26,981 his entire life. As much as we did to try to help him 57 00:03:26,981 --> 00:03:30,426 imagine what it would be like to get a bone morrow barrow, a bone marrow biopsy, 58 00:03:30,426 --> 00:03:35,936 it was beyond the, his worst fears. we got that then, and it showed that when 59 00:03:35,936 --> 00:03:39,338 you're trying to decide should I get a boner biopsy or not, your doctor might 60 00:03:39,338 --> 00:03:43,10 tell you what it will feel like, but that doesn't mean your going to understand and 61 00:03:43,10 --> 00:03:46,358 really grasp what it will feel like, and in his case it was worse than what he 62 00:03:46,358 --> 00:03:52,122 expected. In most medical decisions, the thing we 63 00:03:52,122 --> 00:03:56,920 ask patients to imagine Are not as bad as they imagined they would be. 64 00:03:56,920 --> 00:03:59,758 For example people imagined if they had kidney failure and had to go to dialysis 65 00:03:59,758 --> 00:04:02,708 a few times a week. And have their blood pulled out into a 66 00:04:02,708 --> 00:04:06,446 machine and put back into their body. That they'd be miserable in that 67 00:04:06,446 --> 00:04:08,596 situation. We had, I, in my research I've asked the 68 00:04:08,596 --> 00:04:10,876 general public what do you think your life would be like if you had kidney 69 00:04:10,876 --> 00:04:15,715 failure and needed dialysis? And people imagine being in negative 70 00:04:15,715 --> 00:04:20,424 moods the majority of their waking hours. But when you actually measure the moods 71 00:04:20,424 --> 00:04:23,304 of people who have kidney failure, giving them beepers that even beep at 72 00:04:23,304 --> 00:04:27,970 intermittent periods during the day they'll say what's your mood right now? 73 00:04:27,970 --> 00:04:30,956 We find that people are happy the majority of the time. 74 00:04:30,956 --> 00:04:34,56 And in fact you can't tell the difference in the moods of people with kidney 75 00:04:34,56 --> 00:04:37,406 failure going to dialysis three times a week facing a 20% mortality rate because 76 00:04:37,406 --> 00:04:41,160 of the serious of their, of their illness. 77 00:04:41,160 --> 00:04:44,446 You can't tell the difference between their moods and the moods of healthy 78 00:04:44,446 --> 00:04:47,328 people. People have an ability to emotionally 79 00:04:47,328 --> 00:04:50,892 adapt to chronic illness and disability beyond what they imagine they could do 80 00:04:50,892 --> 00:04:56,550 and when making medical decisions. People often don't recognize how much 81 00:04:56,550 --> 00:04:58,936 they'll adapt. And that can lead them to make bad 82 00:04:58,936 --> 00:05:01,330 decisions. So let's challenge one. 83 00:05:01,330 --> 00:05:04,878 How do you help a patient? Imagine what their life will be like if a 84 00:05:04,878 --> 00:05:08,220 or b or c happen. And a and b or c are unfamiliar health 85 00:05:08,220 --> 00:05:11,160 states they've never experienced. Now Mr. 86 00:05:11,160 --> 00:05:14,851 Andrews case. He had to imagine what it would be like 87 00:05:14,851 --> 00:05:19,10 to go through chemotherapy. We did our best to describe that to him. 88 00:05:19,10 --> 00:05:23,365 The second thing we needed to do then was to help him decide in this midst of what 89 00:05:23,365 --> 00:05:28,370 was very high stakes decision, literally life or death. 90 00:05:28,370 --> 00:05:31,280 And that's the second real difference between medical decisions. 91 00:05:31,280 --> 00:05:35,580 And many other decisions in life, the stakes are so much higher. 92 00:05:35,580 --> 00:05:39,920 Now, funny things happen when people are faced with medical high stakes decisions, 93 00:05:39,920 --> 00:05:44,380 especially ones involving cancer. They feel like they have to do something, 94 00:05:44,380 --> 00:05:47,110 regardless of whether it's in their best interests. 95 00:05:47,110 --> 00:05:50,338 I'll give you an example. We ask people to imagine They had a slow 96 00:05:50,338 --> 00:05:54,10 growing cancer inside their bodies that, that cancer if it was left untreated and 97 00:05:54,10 --> 00:05:57,466 watched for awhile and only treated aggressively if it expanded would have a 98 00:05:57,466 --> 00:06:01,30 5% chance of ending their lives we also told them we could take that cancer right 99 00:06:01,30 --> 00:06:04,540 out with a surgery that the surgery would cure them of the cancer they wouldn't 100 00:06:04,540 --> 00:06:12,850 have to worry about the cancer anymore. But the surgery was quite risky, 10% 101 00:06:12,850 --> 00:06:17,990 chance they would die of the surgery. So, in the one hand 5% chance of dying of 102 00:06:17,990 --> 00:06:22,900 cancer, other hand 10% chance of dying of surgery. 103 00:06:22,900 --> 00:06:26,176 Majority of people said, "Give me the surgery and get it out of me." Almost an 104 00:06:26,176 --> 00:06:31,220 action imperative kicked in, when the C word, cancer came at people. 105 00:06:31,220 --> 00:06:34,665 They would anything they could to get rid of it even if it seems to defy logic and 106 00:06:34,665 --> 00:06:38,450 rationale. So that's part another way that medical 107 00:06:38,450 --> 00:06:42,514 decisions are different. The stakes are high and especially when 108 00:06:42,514 --> 00:06:47,765 the diagnoses we even talk about, things like cancer, create such strong emotions. 109 00:06:47,765 --> 00:06:53,230 They compel people to take action. Even if, potentially, it'd be better to 110 00:06:53,230 --> 00:06:58,228 stand back and do something less than that most aggressive care. 111 00:06:58,228 --> 00:07:00,994 Alright. So, what other things could effect the 112 00:07:00,994 --> 00:07:04,420 kind of decisions that Mr. Andrews faced in this case. 113 00:07:04,420 --> 00:07:08,70 Another is he needed information to guide his decision. 114 00:07:08,70 --> 00:07:11,590 And one of the differences between many decisions we face in life and medical 115 00:07:11,590 --> 00:07:15,55 decisions is that in medical decisions you rely on the doctros often to help 116 00:07:15,55 --> 00:07:20,554 you, to inform you about your choices. That creates problems where doctors don't 117 00:07:20,554 --> 00:07:23,920 know how to speak in a language their patients can understand. 118 00:07:23,920 --> 00:07:26,672 I've found that even with my primary care patients when I'd talk to them about 119 00:07:26,672 --> 00:07:30,813 their blood pressure. I assume that they knew that the blood 120 00:07:30,813 --> 00:07:34,417 pressure meant that the force pushing against their arterial walls was elevated 121 00:07:34,417 --> 00:07:38,868 because their arteries were stiff. And that created problems like risk of 122 00:07:38,868 --> 00:07:42,906 heart attack or stroke. To them, the word pressure meant nervous 123 00:07:42,906 --> 00:07:46,312 and anxiety, anxious. And so they only thought they needed to 124 00:07:46,312 --> 00:07:49,100 take blood pressure pills When they were nervous or anxious, when they were under 125 00:07:49,100 --> 00:07:52,32 pressure. And so fact that I used a word that meant 126 00:07:52,32 --> 00:07:55,82 one thing to me and meant something different to my patients, lead them to 127 00:07:55,82 --> 00:07:59,255 make bad decisions. So, skip blood pressure pills they needed 128 00:07:59,255 --> 00:08:02,0 to take everyday. So we physicians have to educate our 129 00:08:02,0 --> 00:08:05,530 patients in language they can understand. That's often a big challenge. 130 00:08:05,530 --> 00:08:09,210 Mr. Andrew's story reveals another challenge. 131 00:08:09,210 --> 00:08:12,436 We also have to give you accurate information. 132 00:08:12,436 --> 00:08:15,442 In Mr. Andrews case, a 5% chance that his 133 00:08:15,442 --> 00:08:20,656 leukemia would respond to chemotherapy and yet the oncologist told him that it 134 00:08:20,656 --> 00:08:24,350 was 20% odds. Is that a lie? 135 00:08:24,350 --> 00:08:30,42 Well here I want just tell you. It's not just patients who are prone to 136 00:08:30,42 --> 00:08:35,930 strange decisions in medical contexts. We physicians are prone to those too. 137 00:08:35,930 --> 00:08:37,610 And I don't think that that oncologist lied. 138 00:08:37,610 --> 00:08:41,622 I think that oncologist when asked straight up front what are my odds of 139 00:08:41,622 --> 00:08:47,590 getting benefit from the chemo had that 5% number in her head. 140 00:08:47,590 --> 00:08:51,942 And immediately started recalculating because it's so hard to give someone such 141 00:08:51,942 --> 00:08:54,962 dismal news. So she probably thought, hmm, you know, 142 00:08:54,962 --> 00:08:57,910 for five precent but he's younger than the average leukemia patient, he seems to 143 00:08:57,910 --> 00:09:00,638 be a fighter and, you know, maybe the, maybe the studies who told me the five 144 00:09:00,638 --> 00:09:03,498 percent number are a little bit old, maybe the treatments are better than they 145 00:09:03,498 --> 00:09:08,710 were. All of a sudden that five became 20. 146 00:09:08,710 --> 00:09:12,590 And if she was lying to anyone, I think the oncologist was lying to herself. 147 00:09:12,590 --> 00:09:16,208 Because imagine if you were taking care of people with advanced cancer day in and 148 00:09:16,208 --> 00:09:19,556 day out wouldn't you want to convince yourself that they all had a fighting 149 00:09:19,556 --> 00:09:24,8 chance. And so here we are, in fact studies have 150 00:09:24,8 --> 00:09:28,83 shown, if you as doctors. With patients who have advanced cancer 151 00:09:28,83 --> 00:09:31,280 you ask their doctors how long do you think they have to live. 152 00:09:31,280 --> 00:09:34,950 They say oh they have this long to live. Look at the actual evidence. 153 00:09:34,950 --> 00:09:38,12 They only live this long. They overestimate how long their patients 154 00:09:38,12 --> 00:09:41,410 have to live because they have to see hope in the situation. 155 00:09:41,410 --> 00:09:44,290 Then you ask the doctors well if the patient asked how long would you tell 156 00:09:44,290 --> 00:09:47,248 them they have to live. And they said oh I'd tell them they have 157 00:09:47,248 --> 00:09:49,520 this long to live. So here we are. 158 00:09:49,520 --> 00:09:51,804 Here's how long they live. Here's how long the doctors think they 159 00:09:51,804 --> 00:09:54,110 live. Here's what the doctors say. 160 00:09:54,110 --> 00:09:55,700 You can see that gap getting bigger and bigger. 161 00:09:55,700 --> 00:09:59,508 And yet that is the information patients need, to make decisions like Mr.Andrews 162 00:09:59,508 --> 00:10:04,130 faced, on whether to take chemotherapy. We rely on, good information, but 163 00:10:04,130 --> 00:10:09,674 psychology can get in the way of that. So, we've seen several things that differ 164 00:10:09,674 --> 00:10:13,945 between medical decisions. And regular, and other decisions in the 165 00:10:13,945 --> 00:10:15,840 world. Unfamiliar situations. 166 00:10:15,840 --> 00:10:18,210 High stakes. A dependence on the doctor for 167 00:10:18,210 --> 00:10:20,286 information. Where the doctor might already be biased 168 00:10:20,286 --> 00:10:23,650 about what information to give you. The final difference is, we often come to 169 00:10:23,650 --> 00:10:26,112 doctors for advice. And here's how that works. 170 00:10:26,112 --> 00:10:29,708 Let's go back to that cancer scenario where I said you had a cancer inside of 171 00:10:29,708 --> 00:10:33,270 you. 5% chance you'll die of the cancer, 10% 172 00:10:33,270 --> 00:10:37,782 chance you'll die of the surgery. You ask people to make that decision and 173 00:10:37,782 --> 00:10:41,318 they say, oh yeah I'll have the surgery. If you ask people to recommend a 174 00:10:41,318 --> 00:10:44,763 treatment for a friend they say, don't get the surgery, take your chance on the 175 00:10:44,763 --> 00:10:48,704 cancer. We find the same thing happens with 176 00:10:48,704 --> 00:10:50,680 doctors. They make 1 set of decisions for 177 00:10:50,680 --> 00:10:52,988 themselves. But when making, giving advice to 178 00:10:52,988 --> 00:10:56,360 patients, they give a whole 'nother set of recommendations. 179 00:10:56,360 --> 00:11:00,640 We weigh things differently, risks and benefits when we're deciding for ourself. 180 00:11:00,640 --> 00:11:03,846 When we're deciding for others. Another factor that affects medical 181 00:11:03,846 --> 00:11:06,510 decisions. So let me tell you what happened with Mr. 182 00:11:06,510 --> 00:11:08,623 Andrews. He said he wanted the chemotherapy. 183 00:11:08,623 --> 00:11:11,520 We walked out of the room. I was stunned that the oncologist had 184 00:11:11,520 --> 00:11:14,420 changed that 5% number to 20% and I couldn't let him get that treatment 185 00:11:14,420 --> 00:11:18,264 without going back in and seeing what he really needed. 186 00:11:18,264 --> 00:11:21,155 So I went back in the room and I said to him, I just explored his views, his 187 00:11:21,155 --> 00:11:24,308 values, understood where he was coming from. 188 00:11:24,308 --> 00:11:27,556 And I said well let's suppose, just suppose on the off chance that that 189 00:11:27,556 --> 00:11:31,880 chemotherapy had only a One percent chance of benefiting you. 190 00:11:31,880 --> 00:11:34,922 Would you still do it? And he said yes, my, my lover in the 191 00:11:34,922 --> 00:11:39,38 past, died of AIDS. And he would he was a fighter to the end 192 00:11:39,38 --> 00:11:43,310 and he'd want me to fight all the way. So even if it was just a 1% chance, I'd 193 00:11:43,310 --> 00:11:46,947 still take the treatment. At that point I was comfortable with him 194 00:11:46,947 --> 00:11:49,609 undergoing the therapy. And went along with the decision. 195 00:11:51,140 --> 00:11:54,412 So, if you want to learn more, again, read critical decisions. 196 00:11:54,412 --> 00:11:58,52 But certainly you want to understand that all the things you learn about irrational 197 00:11:58,52 --> 00:12:01,536 forces that can affect decisions and many domains in your life are brought up to a 198 00:12:01,536 --> 00:12:06,20 whole new level when it's medical context in your life. 199 00:12:06,20 --> 00:12:09,173 Thanks very much and have a good day.