Before a treatment or major diagnostic test is used, potential adverse effects should be weighed against potential benefits in the context of the patient's individual desires and goals. Health care professionals should always ask themselves the following:
How will the results of the treatment or diagnostic test affect this patient's quality of life?
Are the decisions being made based on these results consistent with this patient's goals of care?
Potential adverse effects include the following:
Death
Complications, including prolonged fatigue and disability
Discomfort
Inconvenience
Cost
Need for additional tests or treatments
Potential benefits include the following:
Cure
Prolongation of life
Slowing of disease progression
Functional improvement
Symptom relief
Prevention of complications
When treatments are very likely to achieve benefits and very unlikely to have adverse effects, decisions are relatively easy. However, assessing the relative importance of these quality of life factors to each patient is important when treatments may have discordant effects. For example, aggressive cancer therapy may prolong life but have severe adverse effects (eg, chronic nausea and vomiting, mouth ulcers) that greatly reduce quality of life. In this case, the patient’s preference for quality versus duration of life and tolerance for risk and uncertainty help guide the decision whether to attempt cure, prolongation of life, or palliation.
The patient’s perspective on quality of life may also affect treatment decisions when different treatments (eg, surgical versus drug treatment of severe angina or osteoarthritis) may have different efficacies, toxicities, or both. Health care professionals can help patients understand the expected consequences of various treatments, enabling patients to make more informed decisions. Discussions that help clarify alternatives should involve shared decision making that accounts for each patient's preferences, and language and concepts should be tailored to each patient's cognitive capacities.
When predicting toxicities and benefits of various treatments, health care professionals should use the patient’s individual clinical characteristics rather than chronologic age alone. In general, the patient’s chronologic age is irrelevant when deciding among different treatments or therapeutic goals. However, life expectancy may affect treatment choice. For example, patients with a limited life expectancy may not live long enough to benefit from aggressive treatment of a slowly progressive disorder (eg, radical prostatectomy for a localized, slow-growing prostate cancer).
Nevertheless, quality of life is important regardless of life expectancy. Thus, invasive treatments that may improve quality of life (eg, joint replacement, coronary artery bypass surgery) should not be automatically rejected for patients with a limited life expectancy. Similarly, deprescribing medications should be considered when treatment risks outweigh benefits because of changes in goals of care (eg, stopping a statin used to lower cholesterol levels for a patient in hospice). In the end, care should be provided as needed to improve or maintain quality of life for patients while being consistent with their goals of care.
