Neurosurgeons are often at odds with the palliative care team with goals of care discussions in patients with brain tumors. Often, palliative care team consult is delayed, fearing that a discussion with the team will lead to earlier withdrawal of care. Neurointensivists are often caught in between, having to balance the need to engage patients and families in end of life discussions, and at the same time, understanding how such a conversation can disrupt previously established neurosurgical plans and derail the therapeutic relationship between the neurosurgeon and his/her patient.
This dilemma – to treat aggressively or to palliate symptoms – exists because of two realities: first, prognostication in neurooncology is imperfect, and second, surgical interventions are not completely harmless. If cancer prognostication were perfect, then decisions to withdraw care would be based solely on the values of the patient and family rather than on a gamble that a therapeutic option will be beneficial. Patient denial (“hoping against hope”, “waiting for a miracle”) will be minimized if physicians can provide accurate prognostic information to the family. If interventions were harmless, then the decision to treat when treatment is not curative or when the benefit of treatment is uncertain, would be easier to make. Unfortunately, that is not the current state of affairs, hence this discussion.
Based on the article I read on 10/08 (see previous blog), I thought it would be interesting to apply the same form of analysis to this issue. I made this table of 8 scenarios, which clarified for myself where I lie in deciding for aggressive treatment or palliation.
I have made the following assumptions:
- the final decision is and should be made by the family and the patient who are fully informed of the prognosis as best available in the current medical literature and the risks and benefits of medical or surgical treatment
- Physicians and health care providers can influence this decision-making process significantly, as well as clergy, friends and family
- we want to save lives whenever possible, and prolong life (with good quality) whenever we cannot. We want to comfort always. We want to be truthful always.
In scenarios 1 and 2, and 7 and 8, where intervention is curative or harmful, the decision is straightforward. The right decision is to treat when intervention is curative and palliate when the intervention is harmful.
In scenarios 3 and 4, where intervention merely prolongs life (with good QOL), and scenarios 5 and 6, where intervention may have no benefit or merely prolongs life without preserving a good QOL, the decision is less clear. To improve decision-making in these scenarios, we should think about the following:
- What is significant prolonging of life? Significant in research studies depends on the p value, which may not align with what the family or patient believes is significant.
- How much disruption of life from the medical intervention is the patient / family willing to endure?
- How certain are we that the intervention has no benefit, or merely prolongs life? Are there outliers? Are there subgroups that respond better, and is the patient possibly in that subgroup?
No matter how frequently I’ve had these discussions with different families in the neurocritical care unit, I have still yet to reach a level of comfort that I’m doing things the right way. The discussion is never easy, but with the stakes involved, I believe the discussion should never be an easy one. If it were, then maybe some degree of thoughtfulness on the case may be lacking.