Monday, December 18, 2006

Some musings on the Sunday Paper: Cancer & Prognosis; Right to die in Italy

I have a keen interest in the way medicine is portrayed in the media (TV, print, etc.). I think most good docs should have a good understanding of how most of their patients may collect information about disease, treatments, and outcomes. There has been a big push for health care to be more openly measured on performance and cost, but even with a lot of metrics out there, I think most of our patients and their families will go on information passed on by friends, and by a report of a great breakthrough in "(insert name of disease here)" on the evening news or in the paper.

So I was relatively pleased to see a large second page article in my Sunday paper about prognostication in cancer. The push for more information to get to the consumer with the benefit of multiple new therapeutic options (of varying toxicity and benefit) has made most people realize that making these decisions can be very difficult.

When a patient in the article was offered a host of choices by her doctor she replied:

"I'm having a little trouble following you," Rastelli, a single mom, said doubtfully.

"I know. This is a lot to take in," said her doctor, Kathy Albain.

They then turned to something called Adjuvant Online. It is a pretty slick JAVA Web based prognostic modeler for Breast Cancer, Lung Cancer, and Colorectal Cancer. It basically will tell you based on a number of disease specific factors, and patient related characteristics, what the difference in mortality is from cancer, therapy, or other disease at five years. It is intended to be used by health care professionals in counseling patients. Of note it is sponsored by a Breast Cancer foundation and AstraZeneca (maker of ARIMIDEX® (anastrozole)).

It is a well put together program with lots of extra information and slides/pictures for shared decision making with your patients. If you are an oncologist you should surely take a look at this site. For palliative med providers, we could consider making programs like this for approximating many other interventions and their values closer to the end of life. For more on evidence based formulation of prognosis you should come to the Annual Assembly at the AAHPM in Feb 2007 and see my 4 hour pre-conference on the topic. (Shameless plug!)

The article also mentioned a Mayo Clinic program called Numeracy, which does a similar thing, but even with my Google skills, I could not find it.

Dateline Rome, Italy
The other article that caught my interest was one that described a case in Italy where a judge rejected a request for withdrawal of a ventilator from a 60 year old man, Piergiorgio Welby, diagnosed with muscular dystrophy as a teenager. He receives artificial nutrition and communicates with a voice synthesizer which reads his eye movements. Apparently he has a constitutional right to refuse treatment and even stop treatment once started, but the Italian medical code (not a law) requires maintenance of life (apparently without a clause about patient choice or at what cost.) Italian physicians stated they could not carry out 'treatments aimed at causing death.' They also mislabeled this as a potential suicide or euthanasia if carried through. First of all it cannot be suicide because the main actor in a suicide is the patient himself. And euthanasia involves the introduction of a new means other than disease progression as the cause. This is more accurately described as withdrawal of medical therapy which then should be argued on its own merits, as opposed to using such polarizing and misunderstood terms as suicide and euthanasia. There was a slight nod in the article to the influence of the Roman Catholic Church with the courts in Italy.

For more article you can use Google News.

A last quote for reflection.

He has even written to Italy's president asking to be taken off the machine that keeps him alive so he can, in his words, "find peace for my tortured and shattered body"

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