As a young Cardiologist in 2005, (right now, I am a part of the elite NSYCA group, which stands for Not So Young Cardiologists’ Association), I was called on to make a decision. A grave decision in fact; something concerning the life of a patient. The patient was a 75 years old frail lady, who was suffering with a severe heart valve disease and was in heart failure. We could partially treat her heart failure after 14 days of ICU care, and then after two weeks of grueling suffering, here was the equation:She required a very high risk surgery for the heart valve which has a death risk of about 70 % and without which she would certainly die. The surgery was going to cost the family a bomb and the family would go into debt forever. Medically speaking, however, the lady required surgery, but was it really worth it?
I sat with the family and discussed both the options with them. In the end they said they understood all the implications and they asked me to take the decision for them considering everything. You know, I was really stuck between the rock and a very hard place. I had to take a decision.
A decision which I had indeed taken…
Would I repent for it later?
Is it usual for patients to ask their doctor the decision on their behalf? Yes! It seems. In a recent survey conducted by the University of Chicago, 8000 hospitalized participants were enrolled. Of these, most told that they prefer that the doctor discuss all the treatment options with them but two thirds of the patients felt that they would rather have their doctor take the decision on their behalf.
Making decisions in the single most stressful task in anyone’s life, but more so in a doctors’. A doctor has to make many decisions in the treatment of every patient. Many of these decisions are taken without the patient’s knowledge. These decisions have to be taken because medicine, at best, is an imprecise science. Take for example, that a 40 year old man is diagnosed with essential -meaning one for which there is no cause found- hypertension. Now his doctor can start him on any of the five classes of anti-hypertensive drugs each with at least five different brands (known to the doctor) and each again with at least three different dose choices. Statistically speaking, his doctor would have at least 75 different, medically correct prescriptions to choose from. That’s why, if the same patient goes to a hundred different cardiologists, the chance of his having a grossly similar prescription from any two cardiologists is extremely remote. Yet, all the hundred cardiologists may be right.
Many of the decisions in the patient’s treatment thus happen without the patient’s knowledge. If so, what are the few other situations in which the doctors give choices to the patients?
The doctors tell the patients regarding the choices in the following scenarios…
- The decision has a great implication for the life of the patient.
- A procedure/ treatment has serious complications
- A situation for which one has to chose a less worse alternative ( the dilemma I described at the beginning of this write-up)
- When the doctor himself is not certain of the right path.
Who should take the decision & why?
In many of the situations requiring a decision about the treatment, the doctor is in an ideal position to take a decision on the patient’s behalf. The doctor has all the medical knowledge about the condition (hopefully) and can understand the social implications of any particular decision.
However, it is sad to know that doctors are but humans.
Most doctors are biased towards a procedure for obvious reasons, but some of them are biased against a therapeutic procedure, just to project that they are not biased. Meaning, if the doctor says a procedure is not required, his patients tend to believe him more and they usually feel happy. Just to make the patients happy, some doctors are biased against some procedures. In either possibility, the doctor is biased one way or the other. It is just that some are worried about their number of procedures; others are worried about what the patients may feel about them. There are some very good doctors, who will take a decision only according to the merits of a situation, but looking from another doctor’s perspective, these decisions may be thought of as biased.
On the other hand, patients’ relatives will do well to make certain things clear to their doctor, before a decision can be reached.
1. They should clearly tell what & how much money can they afford.
2. They should specify how far do they want the doctor to proceed while treating a terminally ill patient.
3. They should also make it clear, if they are even slightly unhappy with a decision by the doctor.
A proper communication is essential to establish a bond between the doctor and the patient. Unfortunately usually, both the doctors, as well as the patients are not very well versed with this art of communication. Only of late some of this art is making its way into the curriculum of the doctors’ education. In making choices, patients & relatives should actively participate. Often not expressing one’s feelings candidly may lead to a totally avoidable unpleasantness later in the doctor- patient relation.
Ultimately, there are people who believe that every point of life is ridden with choices. Even for these people, it behooves well to think that at times, regardless of whose decision it is, the destiny takes over.
Happy decision making!!!