Case 3) Gastric Cancer Case ( Bad News Telling / Terminal Care )


(Case)


Case 3)  75 year old,  male
  The patient had been suffering from loss of appetite, epigastralgia and
general fatigue for several months, and lost 10 Kg of his body weight in
one or two years.  His family doctor diagnosed the patient had a metastatic
liver cancer and need more accurate exams to find its origin.  The patient
was referred to and admitted in A hospital . The origin of the cancer was
proved to be gastric cancer which was on advanced stage.

  The patient wasn't let known real diagnosis because of his family's
decision, and he was told all the exams showed he had only gastric ulcer
and there was no evidence of malignancy.  The patient was a good eater
and his hope was to keep a good table but he hadn't be able to.  He had been
doubting to have gastric cancer by himself but he felt free by the
doctor's explanation.  He discharged from A hospital, and would be followed
by his family doctor after that.

(Question)
  The patient was relieved from his idea of having a cancerous disease by
the doctor's explanation of A hospital.  But his disease was on its advanced
stage and it would get worse and worse in the near future.
  When his suspicion arouse again, how much hope will there be?
  Of course it may depend how his family doctor treat him, though, was it
best things for the doctor of hospital A to give the patient makeshift rest?
  In spite of his hope and effort, the patient would not be able to eat enough
and feeling to be cheated by everyone on his bed to death.  At least he might
have a right to know how he is going to be in near future, if nobody tell him
the real diagnostic name GASTRIC CANCER.
  On the discussion with his family, should the doctor to discuss not only to
know family's will but also to know the patient's will and the family doctor's
opinion?

1994.9.24.
Masashi Shirahama, M.D.
Director, Mitsuse National Health Insurance Clinic
Lecturer, Department of General Medicine, Saga MEdical School
2615 Mitsuse, Kanzaki Gun, Saga Ken, 842-0301 Japan
HQC00330nifty.ne.jp



Case 3)  Japanese case: Lying about Gastric cancer

Here is another case sent by Dr. Shirahama, in which I have made a few
minor editorial changes, with apologies, in hopes of enhancing readability:

Case3) 75 year old, male
The patient had been suffering from loss of appetite, epigastralgia and general
fatigue for several months, and lost 10 Kg of his body weight in one or two
years. His family doctor diagnosed the patient with metastatic
liver cancer and needed more accurate exams to find its origin. The patient was
referred to and admitted to A hospital . The origin of the cancer was proved to
be gastric cancer which was far advanced.
The patient wasn't told the real diagnosis at his family's request, and he was
told all the exams showed he had only gastric ulcer and there was no evidence
of malignancy. The patient was a good eater and had been discouraged because
of loss of appetite. He had been wondering about gastric cancer but felt reassured
by the doctor's explanation. He was discharged from A hospital, and would be
followed by his family doctor after that.

(Question)
The patient was relieved from his idea of having a cancerous disease by the
doctor's explanation of A hospital. But his disease was on its advanced stage
and it would get worse and worse in the near future.
When his suspicion arouse again, how much hope will there be? Of course it
may depend how his family doctor treats him, but was it the best thing for the
doctor of hospital A to give the patient false reassurance?
In spite of his hope and effort, the patient would not be able to eat enough
and might end up on his deathbed feeling cheated by everyone. At least he
might have a right to know how he is going to feel in the near future, even if
nobody tells him the real diagnostic name GASTRIC CANCER.
On the discussion with his family, should the doctor try to find out not only
the family's will but also the patient's will and the family doctor's opinion?

1994.9.24.
Masashi Shirahama, M.D.
Director, Mitsuse National Health Insurance Clinic
Lecturer, Department of General Medicine, Saga MEdical School
2615 MItsuse, Kanzaki Gun, Saga Ken, 842-0301 Japan
HQC00330nifty.ne.jp

Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the Life
Sciences, Michigan State University, East Lansing, MI USA.
E-mail: brody@pilot.msu.edu



Case Analysis by A.R.Jonsen's 4 box theory

Medical Indication
He has advanced gastric cancer with liver metastasis.
There is no indication of surgical operation due to his age.
Chemotherapy may be available for palitive care, but side effect also may
occur.
Oral intake of soft food is possible.
There is no association between gastric cancer and pharingial carcinoma.

Patient Preferences
He is wondering he has gastric cancer.
He has let known that he had cancer of vocal code.
He understands well.

Quality of Life
He is sturbing for satisfaction with his meal.
He communicates with his esophagial voice since his vocal code was operated.

Contextual Features
He is livng with his wife, 81 yo.
Both of his son and daughter are married and live apart from his house, but
they keep in touch together.
Son and Daughter don't want to let their father known he has another cancer.
He lives by NENKIN.
He own a small cake shop, but it has been closed since his wife got her lambur a
che.
Inchargement in his family doctor's place is available.



(Comment)


Dr. Thomas R. McCormick (206)616-1820
Box 357120 UW School of Medicine
Seattle, WA 98195-7120

In the case of the 75 yo man with gastric cancer---the tradition in Japan
of not disclosing a terminal diagnosis contributes to an interesting
conflict between 1) attempting to spare the patient the bad news of a
fatal illness, and 2) depriving the patient of an honest assessment of his
condition that might allow him to carry out his "final agenda."
Incidentally, it creates a third conflict, 3) when it appears inevitable
to the patient that he is worsening,eg. loss of appetite, jaundice, etc.,
then he will realize that he has not known the truth---and this may for
some, interfere with the trust of the doctor and of the family.
--thanks for sharing the cases--I hope my brief comments will be useful.
best regards. Tom McCormick



Reply for Dr. McCormick by our student

  Thank you for your useful comment.  The three conflicts that you showed
us has made the discussion more clear.  The follwing is what we talked on
the 1st discussion.
  We can not neglect the traditon in Japan, otherwise the system seems not
to work well by the people.  For patient's self dicission making, it is
necessary to approach him by a team of his sorrounding people  such as his
family, freinds, family doctor and other medical staff.  His doctor must find
out who has the key to come intimately to the patient preference, or if there
is nobody, how much capacity he has to accept the bad news of his fatal illness.
The discussion is planed to go on two more weeks.
Thanks for your cooporation.



Tomoko Matsuo
(Ph.D.student in University Heidelberg.Germany,
Ph.D.student in Kyusyu university, Legal Philosophy)

The comment for Case 3

The patient should have been informed of his cancer, although not
about his fetal situation, "if he wanted". It is necessary for
patients that there is chance to know about his own body if they want.
the problem is that the patient was not informed of his real
situation in spite of impossibility to be cured, just by his family's
will. His own will must be respected in this situation. As the script
says, he could not trust the people around him, if the fact appears
to him. But if he don't want to know about it, of course we don't have
to do it.

Many years have been devoted to discuss the problem about informing
patient of his terminal disease. Anyway, in my opinion the image of
cancer would be too dramatized as incurable disease than its reality.
Naturally the image is in a sense correct, however, cancer is the
first ranked disease causing death, no matter how severe it is. As to
me, irrelatively strong reaction against cancer can be caused by two
possible fears. One fear is from unknowing reality about our life,
and the other is from anxiety for death.

Unknowing reality

I can not describe clearly what change has happened in our
physiological state during several decades. Nevertheless, there are
many possible reasons to be considered. We have much longer life span
than before, and we are totally surrounded by unhealthy environment
with innumerable artificial materials, for instance chemical stuff in
foods or over all around, car exhausts and so on. These are convenient
on the one hand, but on the other hand harmful and stressful things,
we consume them every day, we must keep this reality in mind. We live
with these risky things, even if they make our life comfortable. This
mixed condition might create a good chance to cancer. I'm not sure
about this and no one could prove it, because our daily life is too
complicated. But if so, to fear cancer would be sometimes nonsense,
or just ridiculous. I think it is high time for us to live with
cancer without unnecessary fear. Medical stuff must make efforts to
let others know this situation.

anxiety against death
 
We are human beings who are designated for limited life, for death,
as everybody knows. However, we live in a so comfortable world as <I
described, it seems possible that nothing threatens us excepting
aging during we live in the healthy condition. Even if we are
suffered from a disease, we are inclined to try as many ways as
possible to cure it, from money to organs from others. However, we
have limited life and so different life span as from person to
person, this fact doesn't change. It is inevitable for us to accept
the fact.

If one has desire to live longer than his or her designated life span
by cancer notwithstanding medical efforts, it is important what makes
him or her think so. That could be fear not only for own death, but
also for the situation after his death, in case that he is still
young or has a family to be supported, or in case that he has a
strong aim to be reached. In these case it would be difficult to
accept near coming death. This fear would be reasonable, should be
accepted and overcome with help from others.

However if one person is in his 50s or 60s and nevertheless fears his
death by cancer, that would be other question. It is correct that
everyone is equally threatened by fear for death, and no one  has
right to determine whether this person has lived long
enough. Nevertheless I could only say that he should think of his
possible death by himself in regard to his age.

However, to make matters difficult, I must agree that we need a hope
even to live with cancer. From ma experience as a nurse I got
following impression that some patients who know their own disease
are inclined to have a hope to be cured and overcome cancer. Of
course this possibility should not be neglected. This positive
thinking of the patient is also important to live with cancer or
hopefully to overcome it. Because I think that the psychological or
mental power of human beings not the least influences his bodily
condition, and we should underestimate its effects. Frankly to say,
it could be more important than to attack cancer with anticancer
drugs until the patient is bodily and mentally exhausted, excepting
cases in what the cancer can be surely overcome.
 

Appendix

That is my personal opinion, but people who have a
experience working in a hospital  and saw this terrible treatment say,
" I would not like to undertake the kind of treatments if I suffer
cancer."  This fact have to be taken into consideration. And I would
like to ask doctors treating cancer with anticancer drugs whether
they would like to undertake it ?
 

That is all what come to my mind so far. I hope that my comment would
be useful even a little. Thank you.
 



Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing, MI USA.

This case would be seen as a relatively straightforward case in U.S. practice.
Having adopted for some years now the general policy of disclosing the true
diagnosis in cases like this, we tend to focus on the risks of not telling rather
than the risks of telling. In this case the risks are well laid out in the "questions"
at the end. This patient cannot be deceived for very long that his condition is
not in fact serious and worsening, and at that time he may well come both to
know the truth, and also to feel cheated and abused by those who had withheld
the truth. Since the period of emotional calm and peace that he could hope for,
upon the reassurance that all he has is ulcer disease, will necessarily be quite
short, it seems highly questionable to try to justify deception on the basis of this
very small, temporary benefit. As the family physician will be forced to deal with
the consequences of this, it would have been highly desirable to have him or her
involved in the decision as to what to tell the patient at the hospital. The family
physician could also help the family members with their own grief and distress,
in a way that would not require that the patient to be deceived in order for the
family to feel better.



Stuart Sprague, Ph.D.
Associate Professor of Family Medicine
Medical University of South Carolina
Anderson Family Practice Center

   In my mind there is a moral difference between telling someone only part of
the complete story and telling someone a falsehood.  Both are right in some
cases and wrong in others, but the mandate against telling a falsehood is
stronger for me, and the number of times it is appropriate is very small.  There
are cultural differences in how this distinction is made and whether it is
considered wrong.  I would not presume to impose one culture on another.  It
does seem to me that the effects of various options can be seen in all
cultures and should play into the decision.  For example, is trust between the
physician and patient or between the patient and his family stronger when
one knows the other may not tell the truth?  Would the patient conduct the
remaining days of his life differently if he knew the truth?  I was a part of a
conversation recently in which the story was told of a patient who was not
given complete information about his case, and his business failed because
of his death earlier than he expected.  His family sued the doctor for
malpractice because he failed to fully inform the patient.  Other things a
patient who knows he may have a limited amount of time remaining might like
to do can be listed.  Taking a long awaited trip, visiting family members not
seen for a long time, completing some task like writing or working on a
project, wrapping up business and financial affairs for family left behind, and
religious observances are examples of what I mean.
  Patients can say when they don't want more details, but they should be
given the opportunity to express that preference.  Open ended questions by
the physician can give them the chance to express how they feel.
Deliberately lying to them seems to be going too far.


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