Transition To Residency · Year 4 · from Transition To Residency
Case 2: Ethical Dilemma and Shared Decision-Making
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Case Presentation
A 55-year-old male with newly diagnosed pancreatic adenocarcinoma with liver metastases is evaluated by a 29-year-old female oncology fellow. Staging indicates stage IV disease with median survival of 6-8 months. The patient is a retired engineer, cognitively intact, accompanied by his wife and adult son. After explaining the diagnosis, the patient asks, "What would you do, doctor?" The fellow navigates this ethically: She first explores his values: "Before I share my thoughts, help me understand what matters most to you in this situation." He values quality time with family over quantity, fears suffering, but wants to "fight" if there's meaningful hope. She provides honest prognostic information: "Based on the stage, we're talking about months rather than years. Some treatments might extend that modestly but come with significant side effects." She presents options: chemotherapy (possible modest life extension, considerable side effects), clinical trials (uncertain benefit, potential for advancing science), or comfort-focused care (optimizing quality of life). She offers a recommendation when asked: "Given what you've shared about valuing quality time with family and fearing suffering, many patients in similar situations prioritize comfort care with palliative services, perhaps with discussion of a gentle chemotherapy regimen if you want to feel you're 'fighting.' But this is your decision, and I'll support whatever you choose." She involves palliative care for goals-of-care discussion. The patient chooses comfort-focused care with palliative chemotherapy consideration, expressing gratitude for honest guidance without paternalism.
Key Learning Points
- Ethical decision-making applies principles of autonomy (respecting patient decisions), beneficence (acting in patient interest), non-maleficence (avoiding harm), and justice (fair treatment)
- Shared decision-making requires eliciting patient values, providing honest information, presenting options, and offering recommendations when requested while respecting final patient choice
- Physicians may appropriately share their perspective when asked, as long as recommendations are based on patient values and do not impose physician preferences on patients