QUESTION: My father was diagnosed with advanced stomach cancer earlier this year. He has already undergone chemotherapy and was scheduled to have surgery to remove the tumour. But, after getting the results of a CT scan, my father’s surgeon now says it’s not possible to operate. What causes us to doubt his opinion is that we feel my father is showing signs of improvement. My father wants the surgeon to remove as much of the tumour as humanly possible. He is willing to sign a waiver to discharge the surgeon from all liability. We want to know if the doctor is obliged to fulfill my father’s request?
ANSWER: Faced with a diagnosis of advanced stomach cancer, it’s understandable that your father wants to do everything possible.
“Certainly patients and families can ask for various treatments. But, ultimately, it is the physicians who decide whether they are willing to fulfill those requests,” says Sally Bean, an Ethicist and Policy Advisor at Sunnybrook Health Sciences Centre.
A treatment should be both medically appropriate and safe. Physicians make that assessment based on their medical training and experience, says Ms. Bean.
From your father’s perspective, this approach may seem unfair. After all, physicians appear to be the ones in control of the decisions.
However, it’s worthwhile noting that a doctor can’t proceed with a treatment without first obtaining the patient’s approval. For a patient to provide informed consent, there should to be a thorough discussion of the potential benefits and risks of the proposed therapy.
Similarly, when a doctor says no to a patient’s request, ideally there should also be an informative discussion with the patient. That might not always happen because of time constraints or other reasons. But if there is something you don’t understand, you should ask the physician for an explanation. If that is not possible at one appointment, you can request a longer meeting so long as it is booked within a reasonably short period of time.
Dr. Calvin Law, Chief of the Odette Cancer Centre at Sunnybrook, says he is often asked by patients to remove tumours when it’s not in their best medical interest.
“Quite frankly I get asked that every week,” he says.
Some patients with advanced cancer will say, “just cut out the primary (tumour); that might stop it from spreading,” he says.
“I understand what they’re thinking. But that’s not how it works,” says Dr. Law who specializes in the treatment of liver, pancreatic and stomach cancers.
Once a cancer has spread to distant parts of the body, cutting out the spot where it started may not alter the course of the disease. The cancer, for instance, can also spread from secondary sites.
“There may be no benefit and, in fact, there may be harm” in operating, he adds. Some cancers wrap around vital tissues. “It may be just physically impossible [to remove a tumour or part of it] without a life-threatening consequence.” Simply put, the patient may not survive the operation or may die soon afterwards of complications from the surgery.
Dr. Law also points out that surgery may lead to a delay in other treatments, which have evidence of potential benefit for the patient. Surgical incisions, in particular, usually need to heal before chemotherapy can begin.
In your father’s case, he did receive his chemo at the outset of his treatment.
The role of doctors is to provide patients with treatment options, using their medical knowledge and practical experience as a guide.
And in Canada’s publicly funded health-care system they have the added responsibility of acting as the gatekeepers to medical treatments.
“The fact is we are sharing one pot of money to apply to everything. We have to fund treatments in an appropriate, evidence-based manner,” says Dr. Law.
Of course, there are “many examples of people being refused surgery at one place and getting it at another,” he adds.
In certain cases, doctors may disagree on what is the most appropriate course of action. Furthermore, some surgeons may have greater confidence in their own abilities to successfully perform a complex operation than their less-experienced colleagues. A doctor can also be wrong.
So, if your father is having lingering doubts about his treatment, he can seek a second opinion. He could ask the surgeon who is reluctant to operate for a referral to one of his colleagues. Or, your father may feel more comfortable going back to his family doctor, or another member of his cancer-treatment team, for a referral.
Whatever he decides, it’s worthwhile having a discussion with those involved in his care. He may find the doctor has justifiable reasons for not wanting to proceed with surgery.
