Let the patient decide

A couple of years ago, I followed two patients who were in similar circumstances: Both had chest pain (angina) from a partially blocked heart vessel. They were very active seniors who wanted to remain that way. But they were also concerned about risks and possible disability as a result of either the disease or the treatment.

The cardiologist and surgeon involved in both cases believed, as I did, that revealing all options was best. Here are the treatment choices explained to each patient:

• A conservative approach would be to prescribe medications that lessen the frequency and severity of pain. I'd prescribe medications to lower blood pressure and cholesterol and to treat other conditions. The patient would have to be careful when exercising but could remain active.
  
  
• A more aggressive approach would be to clear the blockage with angioplasty, insert a stent if needed, and prepare the patient for the possibility of taking blood thinners for life. If the procedure was successful, the patient could return to normal activity, but an artery could become blocked again.
  
  
• The most aggressive approach would be bypass surgery to clear the blockage. If the surgery was successful, the patient could return to normal activity, but the procedure could pose serious health risks, including a heart attack.
  
  

Surprising choices

A reasonable argument could be made for each option, but what mattered most was each patient's preference. Their decisions were too important for me to call the shots. And if I thought I could predict my patients' choices, I was wrong.The patient I thought would prefer aggressive treatment chose the conservative course, and the one I thought would prefer a conservative approach opted for bypass surgery. A year later, both were alive but in very different shape.

The patient who chose conservative treatment returned to playing golf three times a week. He avoided climbing hills and felt great. But the other patient developed a serious complication that left her bedridden and depressed for months. She died of a stroke 18 months after surgery. Despite the outcome, she and her family appreciated the role she had in making decisions before and after surgery. Our relationship remained strong until her death, largely because she, not someone else, remained in control of her treatment.

In my practice, I've tried to help patients and families to better understand the health-care choices available to them, so that they can remain in control of their lives. And I've learned to respect the fact that some people preferred options that I wouldn't choose for myself, because of different values and beliefs.

Patient and doctor get along best when they maintain a balanced, fair relationship and are open and honest with each other. A simple request can make a difference: "Doctor, explain all the options to me. All of them."