Thursday, March 30, 2023

My Tuesday morning clinic is usually a busy and hectic time, filled with patients and dealing with their problems, needs and emotional concerns. I work with a nurse practitioner, Deb, and my clinic is attended by a retired oncologist who kibitzes and helps with occasional advice. One Tuesday we were overflowing and also particularly busy with the presence of an oncology fellow, medical resident on elective and a pre-med student shadowing.

As you can imagine, we often have to make multiple weighty or important decisions in the few minutes per patient that clinic time allows—as Hillel would say, while standing on one foot. My custom is to thoughtfully review every Tuesday patient on Wednesday morning in detail with all the lab studies then completed and make sure we got it all right; to call relevant consults; look at films; and plan the next steps.

A while back, it also permitted me to see my patients from a 30,000-foot view and appreciate the connection between two patients that I had not recognized in the hubbub of a busy clinic.

Patient A (these patients are altered here sufficiently so as to be HIPAA compliant) is a man in his sixties who was diagnosed several years ago with a stage 3 colon cancer that was high-risk for recurrence. He was offered the usual adjuvant chemotherapy to reduce the risk of recurrence but refused—not a very common occurrence. Several years later the tumor did indeed recur to the liver, but was inoperable. (About a third are operable.) At that time, he accepted chemotherapy, to which the tumor responded and shrank, but after several months, he cited personal problems and discontinued therapy. He returned to the clinic on a regular basis but continued to refuse further chemotherapy and his disease gradually progressed—luckily for him, it had been relatively slowly, but he was nearing the end, of which he was aware. He was coming to my office in a wheelchair, weak and frail.

Patient B is a woman in her 90s with a large tumor in the colon and metastases to lung. She had no other serious comorbidities. She was always accompanied by family who emailed or called me frequently about her. We kept her on mild chemotherapy for six months, with some regression of her tumor and no significant side effects.

What struck me on my Wednesday morning review is that these are both patients with advanced disease in whom treatment is, or was, an option. For one, the choice was discontinuation of treatment or passive euthanasia, while for the other, active treatment was undertaken. We cannot know the life and difficulties that have brought both these individuals and families to these decisions—I know that both were obviously aware of the consequences of their decisions and both had caring, supportive families. But the juxtaposition of the two illustrates the choices available for those with advanced disease, and I do not criticize or condemn either; both are right.

Personally, I am not a fan of refusing/withholding life-prolonging therapy when it can be effective for long periods of time with reasonable toxicity, as in colorectal cancer. Nonetheless, if the patient is indeed ultimately incurable, it is obviously his/her decision.

Several countries, like the Netherlands and Belgium, now permit active euthanasia, also known as physician-assisted suicide, for terminal patients. How often are they used? A study from Belgium in the British Journal of Cancer in 2018 reported that for all cancer deaths, 12% made a no-treatment decision (passive euthanasia), while 10.4% opted for physician-assisted suicide. This rate was consistent across cancer types except for respiratory cancers (a cancer with worse symptomatology), which had somewhat higher rates. The desire for euthanasia, passive or active, correlated with physical suffering, either active or anticipated.

In the U.S., physician-assisted suicide is now legal in 10 states, including New Jersey. Its use is, of course, enveloped in multiple conditions and requirements. One of the requirements is that one be a legal resident of the state in order to obtain access—you cannot go to another state for physician-assisted suicide. My wife, Elie, jokingly (I think) says we should keep our house in Teaneck for this reason, just in case.

For The Jewish Link, I would be remiss not to at least refer to halachic attitudes on the subject inasmuch as virtually all sources proscribe active physician-assisted euthanasia. But the withholding of active treatment or cessation of treatment runs the gamut of opinions, which I refer to other scholars in these pages. I reference only the famous story of Rav Yehuda Ha-Nasi’s death, as he was suffering terribly, and the other rabbis were keeping him alive with their prayers, that his maidservant dropped a jug to the ground to make noise and stop their prayers so he could die peacefully, withholding treatment, and the Talmud seems to approve her actions (Ketubot 104a).

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

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