Mike Andrews had a very difficult decision to make.
He was a patient of mine in the hospital who had been admitted with acute
leukemia, that meant his white blood cells had turned into cancer and were
threatening to end his life. In fact, there was not doubt his life was
not going to be A very long one at this point.
We was in his mid 50s and he had a few days, weeks, maybe months to live.
He would either die of leukemia or of the treatment for leukemia, and therein lay
his choice. He had to decide whether to take
chemotherapy that had the potential to extend his life but not cure him of the
leukemia... But was definitely going to make him
miserable in the process. And might even shorten his life.
So he had this difficult decision to make.
I'm Peter Ubel. I'm a physician at Duke University.
I tell Andrew's story in my book, Critical Decisions.
I wanted to tell you now. Are some of the ways that medical
decisions differ from other decisions we face in life.
I will use Andrews' story as part of the way to get into this really fascinating
topic of how medical decisions raise questions and issues and unconscious
irrational forces that aren't necessarily there in other decisions we face in life.
So, Andrews had this choice. Does he take chemotherapy, at the risk of
shortening his life and making himself miserable?
Or does he just get comfort care to relieve the pain and suffering from his
leukemia and live the last few months of his life without going through terrible
treatments? Before he can make that decision, though,
he needed 1 more piece of information. He needed to know the odds would, would
respond to the chemotherapy. And that depended on the results of
genetic testings of his leukemia. The test results came back and I met with
the oncologists, the cancer doctors, outside Mr.
Andrews' room to talk about the results and they weren't good.
The oncologists looked me in the eye and said it's bad news.
At best, there's a 5% chance his leukemia will respond to the treatment.
Terrible news. So we went to the bedside.
The oncologist sat down next to Mr. Andrews and explained what chemotherapy
would entail, the fact that he wouldn't be cured no matter what happened, et
cetera. Andrews understood this all.
He said but doc, I want to know what are the odds that my cancer will respond to
the chemotherapy? The oncologist took a deep breath and
said 20%, Mr. Andrews, 20% chance that you'll respond.
He said well those are fighting odds. Let's go for it.
We left the room and the oncologist signed the orders for the chemotherapy.
What happened here? Well I'm going to get to his story a
little bit more but let me tell you about just a number of factors that went in
here. That's, that highlight how weird medical
decision can be, medical decision making can be.
It starts with the fact that we're often asking patients to make decisions that
are unlike any decisions they faced in their lives, and that force them to
imagine the unimaginable, to predict the unpredictable.
To imagine what it's like to experience something they've never experienced
before. In fact in Mr Andrews case that began
with the bone marrow biopsy we used to diagnose him with leukemia.
A bone marrow biopsy and I sorry to have to describe this to you even, it's
painful even to just here about it. It involves taking a needle about the
size of my pinky, and burring it into a person's hip bone which we try to numb up
with medicine, but frankly we never can cover up all the pain.
And in Andrew's case, was the most painful thing he said he'd experienced in
his entire life. As much as we did to try to help him
imagine what it would be like to get a bone morrow barrow, a bone marrow biopsy,
it was beyond the, his worst fears. we got that then, and it showed that when
you're trying to decide should I get a boner biopsy or not, your doctor might
tell you what it will feel like, but that doesn't mean your going to understand and
really grasp what it will feel like, and in his case it was worse than what he
expected. In most medical decisions, the thing we
ask patients to imagine Are not as bad as they imagined they would be.
For example people imagined if they had kidney failure and had to go to dialysis
a few times a week. And have their blood pulled out into a
machine and put back into their body. That they'd be miserable in that
situation. We had, I, in my research I've asked the
general public what do you think your life would be like if you had kidney
failure and needed dialysis? And people imagine being in negative
moods the majority of their waking hours. But when you actually measure the moods
of people who have kidney failure, giving them beepers that even beep at
intermittent periods during the day they'll say what's your mood right now?
We find that people are happy the majority of the time.
And in fact you can't tell the difference in the moods of people with kidney
failure going to dialysis three times a week facing a 20% mortality rate because
of the serious of their, of their illness.
You can't tell the difference between their moods and the moods of healthy
people. People have an ability to emotionally
adapt to chronic illness and disability beyond what they imagine they could do
and when making medical decisions. People often don't recognize how much
they'll adapt. And that can lead them to make bad
decisions. So let's challenge one.
How do you help a patient? Imagine what their life will be like if a
or b or c happen. And a and b or c are unfamiliar health
states they've never experienced. Now Mr.
Andrews case. He had to imagine what it would be like
to go through chemotherapy. We did our best to describe that to him.
The second thing we needed to do then was to help him decide in this midst of what
was very high stakes decision, literally life or death.
And that's the second real difference between medical decisions.
And many other decisions in life, the stakes are so much higher.
Now, funny things happen when people are faced with medical high stakes decisions,
especially ones involving cancer. They feel like they have to do something,
regardless of whether it's in their best interests.
I'll give you an example. We ask people to imagine They had a slow
growing cancer inside their bodies that, that cancer if it was left untreated and
watched for awhile and only treated aggressively if it expanded would have a
5% chance of ending their lives we also told them we could take that cancer right
out with a surgery that the surgery would cure them of the cancer they wouldn't
have to worry about the cancer anymore. But the surgery was quite risky, 10%
chance they would die of the surgery. So, in the one hand 5% chance of dying of
cancer, other hand 10% chance of dying of surgery.
Majority of people said, "Give me the surgery and get it out of me." Almost an
action imperative kicked in, when the C word, cancer came at people.
They would anything they could to get rid of it even if it seems to defy logic and
rationale. So that's part another way that medical
decisions are different. The stakes are high and especially when
the diagnoses we even talk about, things like cancer, create such strong emotions.
They compel people to take action. Even if, potentially, it'd be better to
stand back and do something less than that most aggressive care.
Alright. So, what other things could effect the
kind of decisions that Mr. Andrews faced in this case.
Another is he needed information to guide his decision.
And one of the differences between many decisions we face in life and medical
decisions is that in medical decisions you rely on the doctros often to help
you, to inform you about your choices. That creates problems where doctors don't
know how to speak in a language their patients can understand.
I've found that even with my primary care patients when I'd talk to them about
their blood pressure. I assume that they knew that the blood
pressure meant that the force pushing against their arterial walls was elevated
because their arteries were stiff. And that created problems like risk of
heart attack or stroke. To them, the word pressure meant nervous
and anxiety, anxious. And so they only thought they needed to
take blood pressure pills When they were nervous or anxious, when they were under
pressure. And so fact that I used a word that meant
one thing to me and meant something different to my patients, lead them to
make bad decisions. So, skip blood pressure pills they needed
to take everyday. So we physicians have to educate our
patients in language they can understand. That's often a big challenge.
Mr. Andrew's story reveals another challenge.
We also have to give you accurate information.
In Mr. Andrews case, a 5% chance that his
leukemia would respond to chemotherapy and yet the oncologist told him that it
was 20% odds. Is that a lie?
Well here I want just tell you. It's not just patients who are prone to
strange decisions in medical contexts. We physicians are prone to those too.
And I don't think that that oncologist lied.
I think that oncologist when asked straight up front what are my odds of
getting benefit from the chemo had that 5% number in her head.
And immediately started recalculating because it's so hard to give someone such
dismal news. So she probably thought, hmm, you know,
for five precent but he's younger than the average leukemia patient, he seems to
be a fighter and, you know, maybe the, maybe the studies who told me the five
percent number are a little bit old, maybe the treatments are better than they
were. All of a sudden that five became 20.
And if she was lying to anyone, I think the oncologist was lying to herself.
Because imagine if you were taking care of people with advanced cancer day in and
day out wouldn't you want to convince yourself that they all had a fighting
chance. And so here we are, in fact studies have
shown, if you as doctors. With patients who have advanced cancer
you ask their doctors how long do you think they have to live.
They say oh they have this long to live. Look at the actual evidence.
They only live this long. They overestimate how long their patients
have to live because they have to see hope in the situation.
Then you ask the doctors well if the patient asked how long would you tell
them they have to live. And they said oh I'd tell them they have
this long to live. So here we are.
Here's how long they live. Here's how long the doctors think they
live. Here's what the doctors say.
You can see that gap getting bigger and bigger.
And yet that is the information patients need, to make decisions like Mr.Andrews
faced, on whether to take chemotherapy. We rely on, good information, but
psychology can get in the way of that. So, we've seen several things that differ
between medical decisions. And regular, and other decisions in the
world. Unfamiliar situations.
High stakes. A dependence on the doctor for
information. Where the doctor might already be biased
about what information to give you. The final difference is, we often come to
doctors for advice. And here's how that works.
Let's go back to that cancer scenario where I said you had a cancer inside of
you. 5% chance you'll die of the cancer, 10%
chance you'll die of the surgery. You ask people to make that decision and
they say, oh yeah I'll have the surgery. If you ask people to recommend a
treatment for a friend they say, don't get the surgery, take your chance on the
cancer. We find the same thing happens with
doctors. They make 1 set of decisions for
themselves. But when making, giving advice to
patients, they give a whole 'nother set of recommendations.
We weigh things differently, risks and benefits when we're deciding for ourself.
When we're deciding for others. Another factor that affects medical
decisions. So let me tell you what happened with Mr.
Andrews. He said he wanted the chemotherapy.
We walked out of the room. I was stunned that the oncologist had
changed that 5% number to 20% and I couldn't let him get that treatment
without going back in and seeing what he really needed.
So I went back in the room and I said to him, I just explored his views, his
values, understood where he was coming from.
And I said well let's suppose, just suppose on the off chance that that
chemotherapy had only a One percent chance of benefiting you.
Would you still do it? And he said yes, my, my lover in the
past, died of AIDS. And he would he was a fighter to the end
and he'd want me to fight all the way. So even if it was just a 1% chance, I'd
still take the treatment. At that point I was comfortable with him
undergoing the therapy. And went along with the decision.
So, if you want to learn more, again, read critical decisions.
But certainly you want to understand that all the things you learn about irrational
forces that can affect decisions and many domains in your life are brought up to a
whole new level when it's medical context in your life.
Thanks very much and have a good day.