Choosing a prostate cancer therapy option for a patient who doesn’t have the capacity to understand the options

When I first saw this patient, there was a note in
the chart from the front desk saying “patient does not read”. I asked if
this was a deliberate decision from the patient, or whether they had meant
to say that the patient was illiterate and could not read.

Unfortunately, the latter is true. The patient is a retired janitor who is
somewhat “developmentally delayed” (I think that’s the current correct
term), and has never been able to learn to read. He has no family and is
functional enough that he does not have a guardian or someone with power
of attorney.

This poses a difficult situation because I diagnosed him with prostate
cancer after doing a biopsy, and tried to explain to him all the options
available for treatment. Prostate cancer is a disease where there are
several treatments choices available (surgery – open or laparoscopic-,
external beam radiation, brachytherapy, cryotherapy, observation etc…),
and the urologist and the patient arrive to a decision together after much
discussion.

Well, there wasn’t much of a discussion with this patient because he did
not truly understand all risks and benefits involved with each option. I
did send him to see the radiation oncologist who agreed with me that the
patient has limited comprehension about the options.

The patient is quite pleasant. He will follow all the instructions we give
him, and our staff has been working extra hard to call and remind him of
all his medical appointments (X-ray, labs, office visits etc…). But this
is a tricky situation. The patient obviously needs treatment, and I am in
the awkward position of deciding for him what the next step should be.

This was an interesting dilemma a colleague of mine faces as she write son
her blog.

My response

This is a great post and will add it to my blog to see what my readers think.
I have to preface my answer with the disclosure that I am a urologist who does
4-6 robotic prostatectomies per week.
I always recommend a second opinion and often have patients ask me to decide for
them.
I had one patient who I biopsied who was very similar to yours, but fortunately
did not have cancer.
My suggestion to you would be to choose for him what you would do for your dad
if it was him.
If you think incontinence would be too much, then radiation has a major
advantage. If you feel that anesthesia is best to be avoided, then external beam
would be the way to go.
If he is young and needs surgery in your opinion, I would recommend that.
The society frowns upon paternalistic physicians (and probably rightfully so),
but this is a good example of paternalism working well.
Good luck.