Dear doctor:
Attached please find the medical records of Mr. Ron C., who is transferring medical care to your office. Ron is a 63-year-old gentleman with recurrent lung cancer, which has spread to his opposite lung and bones. There are multiple treatment choices for his disease, which we have discussed in detail. However, Ron is leaving my care, because he does not trust me.
As you are well aware, metastatic lung cancer is usually incurable. However, it may still be appropriate to treat this disease. In many patients, surgery, chemotherapy, radiation, or a combination of these treatments, can relieve suffering, increase performance and extend life. I discussed each with Ron. He was upset to learn that the treatment is palliative, by which I mean it will not cure, but he is motivated to begin therapy.
However, I made a mistake in our relationship. Ron has not forgiven me.
Every patient should be made aware of all reasonable treatments. Therefore, I try to explain multiple options. I believe, especially when a patient has an incurable disease, that one of the options is to do nothing; no chemo or radiation or surgeon’s knife. Just control symptoms, like pain, and live life, whatever remains. Do not try to treat the illness at all.
Why is “doing nothing” a choice? First, cancer treatments have serious side effects and can make life miserable. In addition, even if the patient tolerates therapy well, it takes away precious time. For some people, drugs and doctors are not worth the marginal gain from toxic treatment. We also must not forget that cancer treatment can be very expensive and that one-third of American families will spend their last dollar on health care.
In the end, it is not my decision; it is up to each patient and family. Too many times patients are dragged away to receive therapy after therapy, until they are wasted, decrepit and dead.
Therefore, I believe that every patient needs to hear the words, “You do not have to do anything. There is no law or rule requiring you to undergo aggressive therapy.”
This is where I screwed up, and Ron went his separate way. Ron heard those words and said, to himself, “Dr. Salwitz is giving up on me.” In that second, Ron’s trust in me to stand by him, to fight for him, to be a doctor with his best interest in mind, was gone.
I tried to explain that by giving him every choice, I was supporting him and guaranteeing that no matter what he decided, I would be there for him. I told him that what was most important was that he live on his own terms and that he do whatever was right, just for him. However, while I tried to say, “You have a choice,” Ron heard, “You are done.”
Please take good care of Ron. He is a warm, wonderful man and deserves the best care. The path he must walk is hard; may it be guided by his desire and your wisdom. I am sorry to have caused him even a small amount of sadness and pain. He deserves better.
Sincerely yours,
James C. Salwitz, MD
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.
