Regret...

As my patients and I discuss choices and review the medical and personal factors that drive decision making, lurking in the background is the "regret factor".

The definition I choose for this regret is based on decision theory. In this sense I define regret as the possible opportunity cost or loss resulting from a decision. That is the difference between the actual payoff of the path taken, versus what might have been gained if the alternative choice had been made. See the following link for more background: en.wikipedia.org/wiki/Regret.

The side effects and trade offs of cancer treatments [ as a negative ] are balanced against the [ possible positive ] future gains. I simplify this important dialogue with the following "regret matrix":

1. The lesson: make sure you have an honest conversation with your medical team. Ensure you understand both sides of the equation; both the advantages and the "cost".
   
   
2. Know that all the "forecasting and probability" data is based on the average for a group of people. Review the statistics module in my companion website.
   
   
3. I suggest a simple model to help decision making in the companion website - click on the ADJUVANT DECISIONS tab in that section.
   

Guilt!

It has been a while. I have been occupied adding content to my web site and getting a feel for the "flow" of thought and information.

I was challenged today by meeting with a very close, and loving family of a elderly father and husband. The children wanted an opinion and travelled a distance from their home town with their father for that purpose. He has an advanced cancer diagnosed and managed by medical oncologists in, and near his hometown.

Now 82 he had been active until he developed dementia a few years ago. His wife of 64 years was present and relayed valuable information regarding his state of mind, present circumstance and comfort. He had heart disease, prior stroke, kidney failure but had NO complaints referable to his marrow cancer. He recognized with zest his family and knew the names of his children, and wife who accompanied him. He had neither pain nor any symptoms he could volunteer. He was in a wheelchair and was unable to give any significant account of himself apart from indicating he "was happy". He had outlived all his friends.

He had no living will or advanced directive and his intelligent and supportive family were his decision makers. His medical oncologist had recommended the placement surgically of a venous access [ port ] device and institution of chemotherapy.

We discussed his palliative options and they understood his condition was incurable. One daughter was a well informed, medically trained and experienced person. In the absence of symptoms, chance for cure and multiple competing disease they were educated about decision making principles, and had his facts applied to that thought process without emotional bias. They understood the consequences of chemotherapy and recognized the treatment side effects and regular office visits were a significant consideration.

He would not be capable of understanding the changes treatment would cause, nor did he have his own voice in this dialogue due to his dementia, and absent a advanced end of life directive.

The family felt collectively and individually guilty and had this, perhaps inadvertently, fueled by his doctor who proposed immediate active intervention and had not given a balanced discussion indicating support only as an option.

The discussion that evolved after my review of the patient, his condition and context allowed them to see their husband/father and not a diagnosis of myeloma. This resolution allowed them to harness their love and protective roles to focus on the quality of his remaining time. No guilt!