Alberta Cancer Foundation

No Easy Answers

In the radiation oncology division at Calgary’s Tom Baker Cancer Centre, Dr. Jackson Wu sees many different patients. Some cases are straightforward and some less so. For example, how aggressively should doctors treat an elderly and frail patient who has lung cancer? Situations like that come with many more questions that Dr. Wu and other health-care providers, as well as patients and their families, must grapple with – questions that do not come with easy answers.

DECISIONS, DECISIONS, DECISIONS: Find out how experts and families measure the options.

“These days, our culture is full of fast food, of getting movies on demand and Googling for everything. We pick and choose and right away the answer is delivered, in an instant,” Dr. Wu says. “But when it comes to more difficult treatments or situations, you can’t just instantaneously get the menu, pick and choose and get it delivered. Sometimes, the decision-making takes more time and thought.”

Complexities in decision-making in cancer care and treatment are varied and, Wu says, may be driven by ethical principles. This is particularly so among the elderly and those who are in a weakened state because of cancer and its treatments. Determining the level of physical condition or deficit and verbalizing realistic and achievable goals for therapy isn’t always straightforward. It’s conversation that requires the involvement of the patient’s family, to help assess the patient’s overall health.

“How aggressive cancer treatment should be is a very difficult question for the patient, the family, and the oncologist, especially in the elderly and in people who are physically and mentally drained after cancer treatment,” Wu says. “You get a lot of debate among clinicians across different disciplines and we don’t have one right answer for it.”

Oncologists such as Dr. Wu, as well as patients and their families, can seek guidance from ethics committees at both the Tom Baker Cancer Centre and Edmonton’s Cross Cancer Institute, which comprise the resources offered by Alberta Health Services’ clinical ethics services. Other organizations also exist to provide resources and support, such as the non-profit Provincial Health Ethics Network.

“Our role is not to find an answer for the people involved, but to provide a process to reflect on the ethical issues, and to provide a number of options for potential decisions that could be made,” Dr. Shane Sinclair, PhD says.

Sinclair is the spiritual care co-ordinator at the Tom Baker Cancer Centre and a postdoctoral fellow. He also chairs the Tom Baker’s Clinical Ethics Committee, which consists of 13 people, including health-care professionals from a variety of disciplines and members of the public. While Sinclair emphasizes that ethical issues are few and far between in the majority of cases at the Tom Baker Cancer Centre, they do exist. That’s where the committee can help, by making people aware of ethical issues and allowing individuals to make their own decisions in an informed manner.

“Oftentimes, there is more than one potentially correct answer,” Sinclair says. “Recognizing that, and allowing people to share their opinions on what they believe to be the right answer facilitates a process and brings people together. It’s nice and affirming to know that this is a tough decision, but we’ve gone through the best processes that we know to ensure that we are making the right decision.”

The more common issues that come to the ethics committee at the Tom Baker include end-of-life decision-making, such as when to withdraw treatment. Another scenario encountered involves patient competencies; how does the family and health-care team respond in the best interests of a patient who does not have the capacity to make his or her own medical decisions?

“Having the presence of a member of the ethics committee who is involved within the treatment area is an opportunity for doctors, patients and nurses to ask questions they might not normally ask,” Sinclair says. Tom Baker Cancer Centre is recognizing the importance of having such a presence; soon a staff ethicist will be working there one day a week. The position is the result of a project that saw an ethicist, Al-Noor Nenshi Nathoo (who is also the executive director of the Provincial Health Ethics Network) embedded in the clinical areas of the cancer centre for four months. Having such a person visible and present, rather than just a phone number to call, was quite positive, Sinclair says.

From Nenshi Nathoo’s perspective, the experience was eye-opening. “I learned that ethical issues surround us everywhere, and that almost every decision about cancer treatment had some moral dimension. The decision or discussion needs to be based, in some way, on the patient’s values,” Nenshi Nathoo says.

The Clinical Ethics Committee also completes formal clinical ethics consults when a major difference of opinion exists between two parties. “We walk through the issues and hear each party’s concerns and provide some guidance around possible ways to resolve those issues,” Sinclair says.

Clinical ethicists also address these ethical questions. “Primarily, I do clinical consultations,” Brendan Leier says. Leier, who is the clinical ethicist at Edmonton’s University of Alberta and Stollery Children’s hospitals says, “About 90 per cent of the consultations come from the health-care team, but it’s not limited to that; I take calls from administration as well as patients and their families.” Leier, also a faculty member at the John Dossetor Health Ethics Centre, says those consults are different for everyone. Consults might solve questions over philosophy of care, differences of opinions between the health-care team and the patient or family, and inter-disciplinary problems between team members.

Leier also holds a teaching position. His academic position at the John Dossetor Health Ethics Centre (Faculty of Medicine and Dentistry at the University of Alberta) involves everyone from educating undergraduate nursing students to physicians. The centre also hosts health ethics seminar series, workshops, symposia and offers graduate courses in a variety of ethics topics.

Leier says constant education is important as new ethical challenges arise. “Allocation of scarce resources is an ethical challenge that is quite common in health care,” Leier says. “New and innovative technology also brings with it ethical challenges.”

Sinclair and Dr. Wu agree, noting that scientific advances, which have created more treatment options for patients, have also brought with them new questions. “When it comes to the technological world that we live in, it brings ethical issues to the forefront,” Sinclair says.

Dr. Wu says that cancer no longer runs its course as it once did, instead, it is altered. “In the past, if you had cancer X, I would be able to tell you that given cancer X at stage I or stage II or stage III, your outlook is XYZ. But these days, because there are a lot of treatment options, that particular outlook has changed,” Wu says.

While there is no easy answer to the many complex questions faced in cancer care and treatment, the various ethical committees and clinical ethicists help by reminding care providers the principles of patient autonomy, dignity, and justice.

“I think the Clinical Ethics Committee increases the ethical climate of the Tom Baker Cancer Centre, on both a clinician and patient and family level,” Sinclair says.

“We’ve done our due diligence, and it allows for people to make the most informed decision possible, while also knowing that they’ve done everything they can, even when a clear-cut decision is not apparent.”

The Provincial Health Ethics Network (PHEN), which plays a supportive role to Alberta Health Services and other health-care providers in Alberta, is developing a resource for patients and family members who are grappling with difficult questions about treatment and health-care options. “This will be in the form of a booklet, and eventually a series of pamphlets available in hospitals, community health centres and libraries,” says Al-Noor Nenshi Nathoo, the executive director of PHEN. A draft document is currently available at Select “Difficult Health Care Decisions.”