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

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.