special subjects
Overview of Medical Decision Making
Defining goals
Before doing complicated, expensive, and/or potentially dangerous tests, doctors typically have a detailed conversation with people regarding the goals of the diagnostic and treatment plan. The typical goals of a diagnostic and treatment plan are to identify and then cure a disease. However, it may not always be desirable to make a diagnosis. The following are just two instances in which this might be true: People do not want treatment for a certain disease. There is no good treatment for a certain disease. For example, if a person in very poor health did not want to have chemotherapy or surgery if a cancer were to be diagnosed, it might not be appropriate for that person to risk the complications of an invasive diagnostic test, such as a biopsy, to diagnose cancer. Sometimes people don't want to have a test because they are worried about the treatment for a disease. A common example is cancer, which often requires unpleasant and sometimes dangerous treatment. Doctors may remind people that they might feel differently if they knew they had the disease and that getting tested does not commit them to getting treated. Similarly, people may not want to have tests for diseases that have no known treatment. An example is Huntington Disease , which is an inherited, progressive, fatal neurologic disorder. Some people with a family history of Huntington disease would prefer not to know whether they have the gene that causes the disease. Other people would like to be tested to help guide life-planning decisions for themselves or family members, who also may benefit from genetic or other testing. Doctors and other primary care practitioners must judge the potential effects on their patients of any diagnostic or treatment recommendations. They must help people weigh the consequences of overlooking a serious condition, even if the diagnosis is unlikely. The same type of reasoning is used in making treatment decisions. Doctors will probably not recommend treatments for people who have a mild condition if those treatments may have serious side effects. However, if the condition is grave but cure is possible, the doctor may advise people that the potential side effects may be worth the risk. Problems may arise when doctors and the people they treat do not share the same perceptions of risk, particularly regarding treatment. A person who hears about a possible serious side effect of a drug may be very concerned, regardless of how rarely the side effect occurs. The doctor may not be as concerned if the possibility of that side effect is remote. Alternatively, the doctor may not understand that what might seem to be a relatively minor side effect for most people may cause great problems for a particular person. For example, a person who drives for a living may be more concerned about taking a drug that can cause drowsiness or that may be forbidden by regulations. Often, the balance between the risk of the disease and its treatment is not clear-cut. A doctor may judge the risks—and benefits—of a treatment differently than the person being treated does. People should discuss these differences in judgment with their doctors. Understanding risks can also help a person weigh options. A doctor may outline several approaches and ask the person to help decide among them. By evaluating the risks of the various choices and then factoring in personal values, a person can make more informed choices about medical care. People should also be clear in expressing their choices to their doctors, especially if they have conditions, such as a terminal illness, that may make it impossible for them to express their wishes at some point later on (see Advance Directives ). 