To treat or not to treat

[NormanH]

This is a thorny question, and this moving article puts the dilemma from  a Doctor's point of view

http://www.guardian.co.uk/society/2012/feb/08/how-doctors-choose-die

My own experience in France so far highlights the fact that issues such as these are much more testing of linguistic competence than even a stay in Hospital or a consultation.

Even in English I am not sure of how I really feel, but to try to express my wishes in French in an extreme situation would be very challenging.

I am also afraid that French medicine is even more technologically arrogant than that in the article.

[Patf]

What do you mean by "french medicine is more technologically arrogant"?

[idun]

NH I could write pages about this.

I remember my french neighbour's mother being distraught that her very elderly mother, with alzheimers had had pnuemonia and they had treat her. Alzheimers was not her only illness either. Therese thought that the Dr's were just after the money and I have no idea as to what their real reasons were. Because at some point to keep a suffering human being alive, is to me, extreme cruelty and is contrary to 'do no harm', which I rightly or wrongly thought was the Dr's oath. And playing god, as they say........ well if they didn't treat and the person survived, well wouldn't that be nature taking over, or an act of god, for the religious.

I am going to do a living will and do not want ressusitating if I am dying.

I have already been confronted with my own mortality. If I had had the illness I was told I could have when I was about 37, I would be very seriously ill now, no cure. For the few years after being told and until  I was tested, after that initial shock, I did get used to the idea of my early demise and one 'lives', because I wasn't ill in any way at that time.  And then the Dr announced that I was clear and the thought arrived, like that, in my head, what will 'get me'!

If I get something now that is mortel, I cannot imagine getting treatment. There is little that I have wanted to do, that I haven't done. It isn't as if I haven't got a few things I would like to do, but if I never do them, I'll not regret them either. And anyway, if I got something now, I'm already playing in extra time compared to what could have been.

[HoneySuckleDreams]

[quote user="NormanH"]This is a thorny question, and this moving article puts the dilemma from  a Doctor's point of view
http://www.guardian.co.uk/society/2012/feb/08/how-doctors-choose-die
[/quote]

Thanks for the heads up on this article. The readers comments make very interesting reading indeed.

(But i don't understand your phrase about french medicine being technologically arrogant, what do you mean?)

 

[NormanH]

I think that French medecine is superb technically, as one might expect from the enormous engineering prowess that is evident, but that there is  even less emphasis on communication and people than shown in the article.

The patient is a bit like a robot and the aim is to mend or change the defective bits.

This is not at all an attack on the system or Doctors in particular, more an observation of a technocratic mind set.

[NormanH]

I think that French medecine is superb technically, as one might expect from the enormous engineering prowess that is evident, but that there is  even less emphasis on communication and people than shown in the article.

The patient is a bit like a robot and the aim is to mend or change the defective bits.

This is not at all an attack on the system or Doctors in particular, more an observation of a technocratic mind set.

Obviously I have personal reason to be very grateful to the superb skill and dedication here.

[HoneySuckleDreams]

I think I understand.

The problem with french consultants we have met (not our dr as he is a nice bloke and open to conversation), is that they deem the patient to be below them..."you can't possible know what's best for you as you haven't been to college", they don't like discourse

You would be amazed at the change in tone of the conversation if you happen to mention that you have a friend who is a top A&E consultant, or top orthopedic consultant etc.

I'm still plowing through the Gruaniad comments

[NormanH]

It's also the separation of the mind and body. A superb technique as a surgeon for example, but not much thought as to the importance  of the morale on getting better.

I am waffling :)

I can't see my Doctors having much sympathy with the idea of not treating someone..

[Sprogster]

Norman, I read a similar article about British doctors with exactly the same conclusion, in that invariably they personally go for minimal treatment and I have heard that when you are terminally ill, the last thing you want to be is subjected to the "heroics" of junior hospital doctors, who at that stage of their career are still struggling with the fact that not all patients can be cured.

I come from a medical family and when I talk to my relatives who are doctors about medical matters, they have a very similar outlook to your article. In fact I can give you a personal example in that last year I was shocked to be diagnosed at a relatively young age with follicular non hodgkins lymphoma, an indolent blood cancer, which is usually incurable but with a long average life expectancy. As it was caught unusually early, I was amongst the five per cent of patients who had a 40% to 50% chance of cure through radiotherapy, but following medical advice from several doctors including a second opinion from a top London teaching and clinical research hospital, I decided not to go down that route because of the high risk of serious life long complications from the radiotherapy in such a sensitive area in the duodenum, near the pancreas and kidneys.  

As I was fortunate enough to have private health insurance and my doctors knew I was from a medical family, maybe they were more forthright, as all of them in response to my question as to what would you do in my situation, said watch and wait, as with an illness that is so slow to develop with which you could live another twenty years being managed with the latest antibody and chemo treatments when eventually you need them, do you want to take the appreciable risk of becoming a gastric cripple, having kidney failure, pancreatis, heart disease or colon cancer from the radiotherapy treatment, at a time when you are still feeling well, when all the clinical evidence shows that early treatment for indolent lymphomas makes no difference to overall survival. So the most important consideration is quality of life, but a lot of patients with this fairly common illness struggle to come to terms with initially doing nothing.

With more agressive cancers having a shorter life expectancy where early treatment is essential, potential long term side effects from treatment are less of a factor, but quality of life considerations is still something that that should be better discussed with patients.

[cooperlola]

My mother has nhl and she was diagnosed at the age of 87.  It took three different consultants telling her it was better left alone at her age since the symptoms are minimal, before she accepted that she was not being treated because it would be better for her that way. She was convinced that treatment was being withheld because it wasn't worth the investment, given her age.  It's a difficult call for the medics too, let's face it.

With the exception of my Romanian woman oncologist, the consultants I have deal with (gynae, orthopods etc) have been universally very human and approachable. At least you see them for more than 5 minutes.  When I had a bad frature years ago and lots of post-op complications (it broke again after six months and I was off work for a year),  I hardly saw the consultant at all and when I did he could never remember who I was. 

I think it's more of a good or bad luck thing rather than being country specific.  However, it must make a difference in the way such types are paid as to the treatment options they offer, wouldn't you think?

[Sprogster]

coops, it all depends on the type of NHL, as there are over thirty varieties, some indolent some aggressive. The aggressive ones usually require immediate treatment as some can be rapidly fatal, but ironically can  have a good cure rate these days as NHL is very receptive to chemo. Ironically, the indolent lymphomas are the most difficult to cure, as they grow so slowly it is difficult to get the last nasty cell, but on the positive side the average life expectancy even without treatment can be many, many years. So if your Mum has what I expect is an indolent lymphoma, at 87 the treatment options would be much more of a risk to her health, than a disease that might well not require treatment for the rest of her life. 

A revolutionary antibody treatment called Rituximab has over the last ten years transformed the treatment of NHL involving 'B' cells and it was recently estimated by Stanford University Hospital in the USA, which is a leading research centre on this disease, that patients diagnosed since its introduction with follicular lymphoma can expect to live eighteen years or more. Therefore, if your Mum does gets poorly it might be worth investigating, as it is increasingly being used as a sole agent to dramatically delay the need for chemo and has very few side effects as compared to chemo. In fact it is also given as a treatment to people with bad rheumatoid arthritis.

The watch and wait approach for indolent NHL until one has advanced symptoms is absolutely the right approach and unusually for the medical profession an area where there is broad consensus, as decades of clinical research has shown to date no overall survival advantage in early treatment. This confuses a lot of patients as it is the exact opposite to the recommended approach for malignant tissue cancers.

Hopefully this information will be of some reassurance for you and your Mum.

 

[cooperlola]

I don't know which type she has to be honest, but all three of the oncologists she has now seen (the most recent at the Royal Marsden) have said to her that the treatments available would be far worse than the desease (which has not manifested itself really in the nearly 3 years since it was diagnosed).  My point was really that it's difficult enough for the medical profession to have to make these decisions and especially  tough if the patient won't believe that radical treatments might not always be the answer.

Thanks for the info'.  I may learn more when I see her about which form she has. 

[Sprogster]

coops,

if your mother was diagnosed three years ago and remains symptom free, she has a very slow growing indolent version of NHL, which her immune system is keeping in check and might do so for many more years if not the rest of her life.

The Royal Marsden is marvellous and there is probably no better place in the world you could have obtained advice.

[HoneySuckleDreams]

http://www.guardian.co.uk/society/2012/feb/13/doctors-radical-plan-organ-shortage

 

[NormanH]

By coincidence I was just reading the same article.

I feel slightly uneasy at the idea of keeping someone 'alive' just to farm their organs, but I haven't though it through yet.