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

Abstract

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. DiscussionCoping strategies are significant underlying issues for many patients. 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.