The Decision to Stop Treatment: Targeting the Reason

“Please, tell me your story,” I said. 

He spoke deliberately, taking me back more than 3 years. There was a lump in his neck and a delay in his diagnosis of human papillomavirus (HPV)-related tongue cancer. Eventually, he had his surgery, but decided not to receive adjuvant chemotherapy/targeted therapy, and then moved across the country. 

When the lump came back, he moved back to find the right answer, the right doctor, the right hospital, and the right staff. Everything had to be "right" before he would pursue further treatment--even though he was aware of the implications of not receiving treatment. Now, he had just finished his second cycle of chemotherapy and the mass significantly decreased in size (sign of a very good response). He was well on his way to finally receiving all of his treatment for a curable cancer, but there was one problem-he wanted to stop treatment.

“Doc, I am ok with my decision.  I’ve lived a full life up to 68 years of age, I’ve seen my children grow up, and I’ve decided to let nature take its course…” He explained, “this treatment is dehumanizing and I won’t go through it anymore." He spoke with assurance about his decision and seemed to have sound, legitimate reasons behind his decision to stop curative treatment that were consistent with his values. 

Except for one problem. 

The “dehumanizing” aspect of the treatment wasn’t so much the treatment; although it may have been precipitated by the treatment. He explained how his whole world had been turned upside down when he came for that second cycle, and he also seemed to relive the unpleasantness of that moment as he explained it. “Doc, I ended up crying like a little child. It was horrible and I never want to have that happen again."

Everyone has the same sense of disbelief when they experience their first panic attack. 

The mind is powerful. It can use flawed logic against itself to spare the pain of anxiety or any other unpleasant emotion--it seeks to protect itself. This is not a decision he would make for someone else.  Similarly, it is very hard to witness a person forego curative treatment; however, a convincing reason in the name of autonomy and personal choice can dissuade many doctors from looking further. 

It should be our job to go further. 

The delays, the moves, the reluctance to undergo treatment previously may have all been evidence for a percolating anxiety problem.  

These issues require genuine care. A new "psychiatric" diagnosis is very delicate in the best of circumstances. With the additional cancer diagnosis, this combination has been known to carry a double stigma. The knowledge to say that he has experienced a real and classic-type of panic attack probably in the setting of an underlying anxiety disorder can be very powerful. It can also be very liberating for the patient who has been suffering with this pain for a period of time. It can be therapeutic in itself to know that it has a name, that many other people experience a similar phenomenon, and that it can be successfully treated.   

It is common that psychological/psychiatric illness is not promptly recognized or treated. In the setting of cancer, the ramifications can be devastating and deserves full attention during the patient "review of systems." In this particular case, the delays in diagnosis were a red flag indicating a problem, such as the unaddressed/untreated anxiety disorder, that is clearly not as simple as a reasonable patient preference.

Disclosures:

Daniel McFarland is a clinical fellow in hematology and medical oncology at Mount Sinai Medical Center in New York City and a member of the American Psychosocial Oncology Society. He is dually trained in internal medicine and psychiatry. As part of the American Psychosocial Oncology Society, Dr. McFarland is currently collaborating with Dr. Jimmie Holland at Memorial Sloan Kettering Cancer Center in an effort to bring psychosocial issues to the attention of oncologists as they treat patients in the new era of personalized medicine. The views expressed are his own.

Daniel McFarland is a clinical fellow in hematology and medical oncology at Mount Sinai Medical Center in New York City and a member of the American Psychosocial Oncology Society. He is dually trained in internal medicine and psychiatry. As part of the American Psychosocial Oncology Society, Dr. McFarland is currently collaborating with Dr. Jimmie Holland at Memorial Sloan Kettering Cancer Center in an effort to bring psychosocial issues to the attention of oncologists as they treat patients in the new era of personalized medicine. The views expressed are his own. - See more at: http://www.oncotherapynetwork.com/lung-cancer-targets/cancer-patients-going-distance#sthash.SqYQYgpb.dpuf

Daniel McFarland is a clinical fellow in hematology and medical oncology at Mount Sinai Medical Center in New York City and a member of the American Psychosocial Oncology Society. He is dually trained in internal medicine and psychiatry. As part of the American Psychosocial Oncology Society, Dr. McFarland is currently collaborating with Dr. Jimmie Holland at Memorial Sloan Kettering Cancer Center in an effort to bring psychosocial issues to the attention of oncologists as they treat patients in the new era of personalized medicine. The views expressed are his own.