Ethical Challenges in Evidence‐Based Management of an Elderly Adult with Cancer without Decision‐Making Capacity

Abstract

To the Editor: WM, a 72-year-old Cuban-American Vietnam War veteran with a history of stroke with residual dysarthria, syphilis, hepatitis C, prostate cancer, schizophrenia, and advanced dementia, was admitted from a nursing home after being found on the floor, probably after an unwitnessed fall. Upon admission, he was febrile and tachycardic and had radiographic evidence of lobar pneumonia. Treatment with intravenous fluids and antibiotics was instituted. Hospital course was complicated by delirium and agitation, requiring use of restraints. A geriatrics consultation was sought to assist with management of delirium and to discuss goals of care. WM had emigrated from Cuba several decades before, was unmarried, had no family in the United States, and lived alone before nursing home admission 5 years before. There were no documented advance directives, nor could they be elicited at time of admission because of marked deficits in speech and cognition. In particular, when asked at the time of consultation, whether he knew of his diagnosis of prostate cancer, he responded, “No.” When asked about whom he trusted most in the world to make health-related decisions for him, he replied, “President Obama.” On examination, WM was a thin, unkempt gentleman who appeared older than his age and needed assistance with most activities of daily living. Four months before presentation, he had undergone a prostate biopsy to evaluate a prostate-specific antigen level of 60 ng/mL. Pathology revealed a Gleason 7, Stage IIB tumor; follow-up bone scan to exclude metastases was equivocal. Hormonal therapy with a gonadotropin-releasing hormone analogue was started 1 month later. Thereafter, he was considered for radiation therapy (RT) that had begun 1 week before presentation. An administrative decision was made to continue RT after he was stabilized. One month later, he was readmitted with subdural and subconjunctival hemorrhage and facial fractures resulting from another fall. During this admission, even as he was being considered for a percutaneous endoscopic gastrostomy tube, the geriatrics team strongly advised against any artificial nutrition or further RT. Finally, RT was stopped in light of the patient's “poor prognosis.” He lived at the nursing home for another 6 months. The American Urological Association recommends definitive therapy rather than active surveillance for localized high-risk cancer (Grade 2C),1 but observational data comparing the different therapeutic modalities are limited, particularly in older adults. For instance, the survival benefit of radical prostatectomy over watchful waiting in men with early-stage prostate cancer is confined to men younger than 65.2 This results in a lack of clear guidelines regarding the standard of care for elderly men with prostate cancer. Also, dementia reduces survival, and elderly adults with cancer and dementia have higher mortality from cancer and noncancer causes.3, 4 Moreover, there is evidence that functional dependence is a predictor of poor outcome in older adults with cancer.5 This individual had neither capacity nor any documented directives. The conundrum is around making a decision to deliver curative therapy to a young-old adult with clinically localized high-risk prostate cancer but who has considerable cognitive and functional deficits that may limit not only the success of therapy, but also the enjoyment of any prolonged life as a result of that therapy. Individual preference is an important aspect of evidence-based medicine that incorporates best available evidence with clinical experience.6 In the absence of decision-making capacity in critically ill individuals, physicians generally resort to the surrogate decision-making process to assist in directing care, especially at the end of life. This begins with review of advance directives if any and discussion with family members and healthcare proxies. In the absence of these directives, the Substituted Judgment standard is used, wherein the decision-maker must have a clear and detailed understanding of the individual's values, preferences, and thoughts regarding health care and end of life.7 When even this is not possible, the Best Interests standard is considered appropriate and legal. This involves the application of the principle of beneficence and attempts to weigh the potential burdens and benefits of treatment for this individual in this particular situation.8 The President's Council on Bioethics professes that incapacitated adults should receive best available care yet clarifies this may not always extend biological life and advocates careful attention to comfort care and pain management. In conclusion, this case highlights the clinical and ethical dilemma for physicians treating elderly adults without decision-making capacity. Greater participation of older adults in clinical trials to improve the quality of evidence and greater understanding of ethical principles by physicians treating older adults are vital. Conflict of Interest: None. Author Contributions: R. Ramaswamy is solely responsible for concept and design, analysis and interpretation, and preparation of the manuscript. Sponsor's Role: There was no sponsor for this letter.