Science, Ethics, and the Making of Clinical Decisions: Implications for Risk Factor Intervention
ABSTRACT Recent improvements in the clinical care of individual patients are rooted in advances in two distinct fields of modern medicine: biomedical research and clinical ethics. In this article, we review the differing roles of these two disciplines in guiding decision making for individual patients. Particular attention is placed on decisions involving risk factor intervention, using the common problem of mild hypertension as an illustration. Both the importance and the limitations for decision making of some recently published clinical trials are reviewed. Differences in interpretation of these trials are a source of major disputes about the proper threshold for medical intervention. The ethical aspects of treatment decisions are then reviewed, with particular emphasis on the doctrine of informed consent and on the role of patient participation in treatment decisions. Finally, new directions for clinical research are suggested that may yield a more complete scientific basis for treatment decisions and that may aid in fulfilling the ethical ideals that underlie the physician-patient relationship.
- SourceAvailable from: Russell S Phillips[Show abstract] [Hide abstract]
ABSTRACT: Context.— Previous studies have documented that cancer patients tend to overestimate the probability of long-term survival. If patient preferences about the trade-offs between the risks and benefits associated with alternative treatment strategies are based on inaccurate perceptions of prognosis, then treatment choices may not reflect each patient's true values.Objective.— To test the hypothesis that among terminally ill cancer patients an accurate understanding of prognosis is associated with a preference for therapy that focuses on comfort over attempts at life extension.Design.— Prospective cohort study.Setting.— Five teaching hospitals in the United States.Patients.— A total of 917 adults hospitalized with stage III or IV non–small cell lung cancer or colon cancer metastatic to liver in phases 1 and 2 of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).Main Outcome Measures.— Proportion of patients favoring life-extending therapy over therapy focusing on relief of pain and discomfort, patient and physician estimates of the probability of 6-month survival, and actual 6-month survival.Results.— Patients who thought they were going to live for at least 6 months were more likely (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.8-3.7) to favor life-extending therapy over comfort care compared with patients who thought there was at least a 10% chance that they would not live 6 months. This OR was highest (8.5; 95% CI, 3.0-24.0) among patients who estimated their 6-month survival probability at greater than 90% but whose physicians estimated it at 10% or less. Patients overestimated their chances of surviving 6 months, while physicians estimated prognosis quite accurately. Patients who preferred life-extending therapy were more likely to undergo aggressive treatment, but controlling for known prognostic factors, their 6-month survival was no better.Conclusions.— Patients with metastatic colon and lung cancer overestimate their survival probabilities and these estimates may influence their preferences about medical therapies. MOST METASTATIC solid tumors, including lung and colon cancer, are incurable and life expectancy is short. Cancer patients and their physicians are often faced with a fundamental choice between cancer-directed therapy and supportive care that emphasizes symptom management rather than control of the underlying disease. Even in incurable solid tumors, cancer-directed therapy may prolong average life expectancy by several months and palliate symptoms in some but is often associated with treatment-related toxic effects. There is substantial variability in the choices that are made about these alternatives. For example, among patients diagnosed as having metastatic colon cancer in 1990, 42% received chemotherapy as a component of their treatment, while 58% did not.1 We believe that patient preferences should drive choices between alternative therapies, especially when life expectancy varies little and quality-of-life considerations are prominent. Cancer patients' ability to participate in making decisions about their care may be limited by several factors, however. Some patients may be too ill or too overwhelmed emotionally to play a major role in establishing the goals of therapy. Among those who wish to participate, potential barriers include lack of physician support for patient decision making, insufficient patient knowledge of the likely outcomes of their disease, and lack of information concerning the effect of alternative strategies on outcomes. Several studies have documented that cancer patients' understanding of their prognosis is imperfect and that they tend to overestimate the probability of long-term survival.2- 6 For example, in 1 survey of patients with metastatic cancer, 37 believed that treatment would cure them and 60% thought that it would control their metastatic disease.5 Patients' preferences for care reflect their values, their understanding of their illness, and their understanding of the risks and benefits associated with treatment choices.7- 10 Studies of cancer patients' values regarding trade-offs between quality and quantity of life have shown substantial interpatient variability.11- 13 If patients do not understand their prognoses accurately, then their decisions about trade-offs between treatment choices may not reflect their true values. We examined the relationship between cancer patients' estimates of their prognosis and their life-support and treatment preferences. The objectives of the analysis were to determine (1) whether patients' prognostic estimates were independent predictors of their treatment choice, (2) whether patients' prognostic estimates were concordant with their physicians' estimates, (3) whether patients' or physicians' estimates were more accurate, and (4) whether patients' treatment preferences influenced their medical outcomes.JAMA The Journal of the American Medical Association 279(21):1709-1714. DOI:10.1001/jama.279.21.1709 · 30.39 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Ambulatory care training is increasingly important in internal medicine. Such training centers on the practice where residents and faculty see their patients; thus, features of the practice model influence what residents learn. A resident-faculty group practice affiliated with a division of general internal medicine has many advantages. In such a practice, learning centers on resident-patient interactions, around which a comprehensive teaching program must be built. Major features of such a program include the mentoring of residents by faculty who work with them longitudinally and the presence of a well-balanced structured curriculum addressing clinical and nonclinical topics related to patient care. Teaching residents to interact and communicate with patients is crucial; approaches include role-modeling by faculty, use of videotaping, and role-playing and other innovative methods. Feedback is integral to learning and helps shape the attitudes and values that permeate residents' practices.Journal of General Internal Medicine 01/1990; 5(1 Suppl):S15-26. DOI:10.1007/BF02600434 · 3.42 Impact Factor
Article: A. Positions and Honors