Ethical Dilemmas in Gynecologic Oncology—Practice Points for the Oncology Practitioner

Oncology & Hematology Review, 2012;8(1):18–20

Abstract:

Gynecologic oncology is a unique field in which physicians frequently become engaged in, and manage, ethical dilemmas. Understanding the features of patients who receive ethics consults is crucial for maintaining continuity of care and identifying areas for physician education. A review of the MD Anderson Cancer Center clinical ethics database and institutional medical record was performed for gynecologic oncology patients receiving ethics consults from 1993 to 2008. Data abstracted included patient demographic and clinical information, clinical case types, and key underlying issues. Information on all gynecologic oncology patients seen during the study interval was also obtained to define a base population. Summary statistics were generated, and comparisons between consult and base populations were performed. Forty-one consults were conducted. Six (15.4 %) patients had established medical power of attorney, and seven (17.1 %) had a living will. The distribution of disease sites in consult patients was similar to the base population, except for gestational trophoblastic neoplasia, which was overrepresented (7.9 versus 0.8 %, p<0.0001). Compared with the base population, there was a greater proportion of consult patients who were African-American (33.3 versus 10.9 %, p<0.0001), had Medicaid (15.4 versus 4.8 %, p=0.002), or were self-pay (15.4 versus 5.4 %, p=0.009). The most common clinical ethics case types involved identifying levels of appropriate treatment. Common underlying issues included family dynamics and patient coping mechanisms. Ethics consultation provides a substantial resource in identifying relevant psychosocial issues experienced by gynecologic oncology patients, on which physician educational initiatives may be based.

Acknowledgment: The authors would like to thank the patients featured in this article. Names have been fictionalized to protect their privacy.
Keywords: Gynecology, clinical ethics, ethics consultation, oncology, advance directives, end-of-life decisions
Disclosure: The authors have no conflicts of interest to declare.
Received: February 21, 2012 Accepted March 07, 2012 Citation Oncology & Hematology Review, 2012;8(1):18–20
Correspondence: Colleen M Gallagher, PhD, FACHE, Chief and Executive Director, Integrated Ethics in Cancer Care, Unit 1430, PO Box 301402, Houston, TX 77230-1402. E: cmgallagher@mdanderson.org

Gynecologic oncologists play a crucial role not only in the physical treatment of their patients, but also in the emotional and psychological adjustments to their cancer diagnoses. Frequently, this involves addressing ethical issues, including end-of-life decision-making and mediating family disagreements about treatment goals. We recently reported on a review of the ethics consults for gynecologic oncology patients at MD Anderson Cancer Center.1 The five most common primary clinical ethics concerns were cited (see Table 1). Several cases in particular stood out as good teaching examples that highlighted themes commonly encountered by our patients. Here we address those cases and suggest points for practitioners to consider when they experience similar situations.
Case #1—Coping Strategies in a Patient with Advanced Carcinoma (Level of Appropriate Treatment—Code Status)
Mrs Smith is a 53-year-old white female with progressive primary peritoneal carcinoma. She had previously undergone extensive surgical resection and chemotherapy, and was noted to have metastases to her femur, ribs, and vertebrae. The patient was admitted to the hospital because of spinal cord compression due to vertebral metastases and underwent palliative radiation. Mrs Smith’s oncologist had discussed do-not-resuscitate (DNR) status with her, and the patient was reluctant to agree to such status. She noted that she did not want to ‘quit’ her fiancé and that she did not want to give up if “God puts his hand down and cures me.” An ethics consult was requested to discuss the futility of further medical intervention and assess the patient’s hesitancy to proceed with palliative measures. The patient’s coping strategy was subsequently identified as the primary underlying issue.
Discussion
Coping strategies are significant underlying issues for many patients. For Mrs Smith, managing her relationship and reconciling religious beliefs with medical realities posed challenges both spiritually and psychologically. A patient’s success in coping with disease is often associated with psychological distress and psychiatric symptoms, the degree of which vary from person to person.2 In 2006, de Faye et al.3 reported that perspective-taking, seeking support, and resignation/acceptance are frequently utilized coping strategies in persons with cancer, and that patients may employ different strategies when faced with specific stressors. For example, patients with social concerns are more likely to employ ‘hope’ and ‘spiritual support’ compared with women with physical ailments, who more commonly engage in direct action to address concerns.3 In a review of women with breast cancer, Classen et al.4 reported that patients who described their coping styles as having a ‘fighting spirit’ or demonstrating more emotional control had better psychological adjustment to their diagnoses than those women lacking such styles.
References:
  1. Schlumbrecht MP, Gallagher CM, Sun CC, et al., Ethics consultation on a gynecologic oncology service: an opportunity for physician education, J Cancer Educ, 2011;26:183–7.
  2. Epping-Jordan J, Compas B, Osowiecki D, et al., Psychological adjustment in breast cancer: processes of emotional distress, Health Psychol, 1999;18:315–26.
  3. de Faye B, Wilson K, Chater S, et al., Stress and coping with advanced cancer, Palliat Support Care, 2006;4:239–49.
  4. Classen C, Koopman C, Angell K, Spiegel D, Coping styles associated with psychological adjustment to advanced breast cancer, Health Psychol, 1996;15:434–7.
  5. Brody D, The patient's role in clinical decision-making, Ann Intern Med, 1980;93:718–22.
  6. Gross M, What do patients express as their preferences in advance directives?, Arch Intern Med, 1998;158:363–6.
  7. Hanson L, Rodgman E, The use of living wills at the end of life, Arch Intern Med, 1996;156:1018–22.
  8. Kierner K, Hladschik-Kermer B, Gartner V, Watzke HH, Attitudes of patients with malignancies towards completion of advance directives, Support Care Cancer, 2010;18:367–72.
  9. Pitceathly C, Maguire P, The psychological impact of cancer on patients' partners and other key relatives: a review, Eur J Cancer, 2003;39:1517–24.
  10. Maguire P, Walsh S, Jeacock J, Kingston R, Physical and psychological needs of patients dying from colo-rectal cancer, Palliat Med, 1999;13:45–50.
  11. Gysels M, Higginson I, Caring for a person in advanced illness and suffering from breathlessness at home: threats and resources, Palliat Support Care, 2009;7:153–62.
  12. Winkler E, Reiter-Theil S, Lange-Riefs D, et al., Patient involvement in decisions to limit treatment: the crucial role of agreement between physician and patient, J Clin Oncol, 2009;27:2225–30.
  13. Brett A, Jersild P, "Inappropriate" treatment near the end of life: conflict between religious convictions and clinical judgment, Arch Intern Med, 2003;163:1645–9.
Keywords: Gynecology, clinical ethics, ethics consultation, oncology, advance directives, end-of-life decisions