Navigating patients’ “less important” health problems

The debate about the overuse of CT scans and potential harms from the resulting ionizing radiation came up again this week with a well-written and balanced article in The Washington Post called “Should you worry about the radiation from CT scans?” (the painting credited to Kai Ti Hsu in the article is worth the click alone). I agree that particularly for young and/or healthy people, doctors should work to minimize the number of CT scans. But this article reminded me of a situation I (and I’m sure all oncologists) encounter regularly: the patient with advanced cancer who refuses a CT scan because of their fear about the harmful side effects they have read about in articles like the one linked above. I then find myself in the predicament of finding a compassionate way to explain to my patient that the 0.05% (1 in 2,000) additional risk of a second cancer 20 years down the road is not really a concern for someone who perhaps has a life expectancy of 3-6 months. It’s also amusing to me when someone states they will absolutely not get another CT scan while at the same time agreeing to a course of radiation to treat their tumor; I can explain that the radiation treatment is 7,000 times the dose of a CT scan but still some people have the fixed idea that CT scans are evil.

A similar situation happens when cancer patients are admitted to hospital near the end of life, with days to weeks left to live. Occasionally the patient or their family will want to intensively monitor their blood pressure or sugar levels (if they are diabetic) and insist on changes to medications if their levels are not where they should be. Again, I used to personally struggle to find a way to gently explain that high blood pressure or high sugars are not a priority at this stage of life. I finally realized that what this situation actually represents is perhaps the last aspect of a person’s life that they or their family can control. Their cancer has progressed despite months or years of tough treatments. The dying process is not something that people feel they have control over, at least not until physician-assisted dying becomes legal and available in Canada. But excellent glucose control in an 80-year old man who has had diabetes for 30 years is a source of pride and something that can still be managed despite everything else going on. So I have adjusted my attitude; I advise patients that we can be more lenient with the numbers but assess how important it is to them to feel like they can still actively manage that aspect of their health. And if their numbers are still important to them, I am happy to try medication adjustments despite the obvious lack of any long term benefit.

I believe that this feeling of control is also what leads some people to refuse opioids (like codeine or morphine) despite severe cancer-related pain because of their fear of becoming “addicted to painkillers”. While recognizing that we are in the midst of an opioid addiction crisis, I have never found the courage (or an appropriate way) to tell a patient “It’s ok if you become addicted in order to be comfortable for the last few days/weeks/months of your life”. Does anyone else have an approach to this situation?

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4 thoughts on “Navigating patients’ “less important” health problems

  1. Very good summary of the topic, one that I’ve certainly encountered many times. I’m especially glad that you discussed how often issues arise that are both sides of the same — some patients don’t want any scans, even when they are appropriate, while others want many more than are likely to provide benefit. Very difficult to develop appropriate systems when any policy is likely to yield complaints from at least one, if not both, sides of an issue.

    Just some spitballing some thoughts for discussion: could some patients’ desire for control, which you discuss in your article, is related to decline in trust that physicians have patients’ values and best interests at heart? Could we reduce patient desire for unnecessary interventions by increasing patients’ and the public’s belief that doctors do, in fact, know what they are doing? What is the best way to achieve this — at least anecdotally we hear that trust in doctors is at an all time low now and trending in the wrong direction? Is that true or not? Is the ubiquity of such demands a relatively new phenomenon or did it exist even in past (possibly more paternalistic) eras?

    This issue of trust can be especially difficult to navigate as trainees, since we don’t have even the sometimes brief rapport and continuity that patients’ regular physics have built up with them. Maybe this is a downside of the modern era of team-based medicine, where there are many cooks involved in a patients’ care, sometimes with contradictory ideas and messages? I’d love to hear your learned thoughts on these matters.

    One final quibble: your article states that the approximate risk of developing a second cancer from a CT scan (~10 mSv exposure) is 1/2000. However, based on the WaPo article you linked to as well as Hall’s textbook of radiobiology, 1/2000 is the risk of developing a FATAL cancer as a result of that exposure. According to Hall, the lifetime risk of developing any cancer from a 10 mSv exposure is 0.1%, or 1/1000.

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    • Thanks for your comments Dr. Klein. I will adjust the article regarding the stats about second cancers.
      Regarding the eroding trust of the public in physicians. I think that the people who don’t believe doctors are doing what is in their patients’ best interests are a small minority, but probably an increasing minority according to reports. I have to believe it’s the same psyche that leads to the growing belief in many conspiracy theories, such as the one that “Big Pharma” or the government has the cure to cancer but is withholding it. I’m not sure there is anything anyone can do to convince this small population that doctors are doing whatever we believe is in our patients’ best interests.

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  2. I’m also glad that Jay is addressing these issues and I think they’re especially important to discuss in the oncology field. I hadn’t contemplated the issue of “control” at the EOL before, but Jay I think you make some very insightful points, and blood sugar testing, etc.– probably cost the health care system little and don’t convey much harm on the patient, so I agree, if it makes the patient/family happy, let it go. On the issue of refusal of opioids to ease pain at the EOL, however, I wonder if you feel you cannot be straightforward with patients that they have weeks to months to live and that opiod addiction is unlikely to become a problem? I agree we encounter many patients and families who seem to be in denial about their prognosis, however, I also have personal experience with oncologists who are simply reluctant and/or uncomfortable admitting that they have little/nothing to offer other than comfort measures. Even when we (the patient/caregiver) were practically begging for a frank discussion of what the end would look like, or how we could avoid unnecessary/futile tests and treatments — it was our oncologists who were encouraging us to keep trying. In cancer, death is not a fail. The fail would be necessary suffering in our final days.

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    • Thanks for your thoughtful comments. Your remark about an open conversation about death reminds me of this article from last year:. I must say I personally don’t think this is an ongoing issue (doctors not being honest with patients that they are dying) at least in the healthcare system in which I work (in Toronto, Ontario). But I read about this time and time again mostly in articles from the US. Perhaps though when doctors try to use sympathetic language and not necessarily use the term “you’re dying” (or similar), we aren’t being clear enough and patients aren’t getting the message when we think they are. Food for thought…

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