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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