A Therapeutic Alliance

Once the patient is able to decide about further treatments, their benefits and possible risks should be discussed and the patient should be informed that he has the right change his mind, when he considers the benefits do not outweigh the side effects. Too often a new treatment line is introduced and there is no discussion about how the patient feels about it. Bitterness of having paid a too heavy price might then occur if the treatment fails to respond to the expectations. Because of fear that the patient refuses a medically reasonable treatment, clinicians often encourage the patient by minimizing its side effects. Such an attitude evokes in the patients a feeling of isolation and hampers the therapeutic alliance, which is most important during the progression of disease. On the contrary, if the clinician is sensitive to the patient's ambivalence, which is an adequate feeling towards the introduction of further treatments after relapse, he is perceived as a careful and competent professional and as a trustful partner. If a patient refuses further treatments, guilt about this decision (for example towards significant others) should not be increased by making the patient feel that he has made an unreasonable choice.

Oncology clinicians also have to accept a patient who is not complying with medical propositions. Such propositions may be reasonable from a medical point of view, but unacceptable for the patient from a psychological point of view. There is no hierarchy between body and mind, and no hierarchy between physician and patient when it comes to making decisions about further treatments. A clinical vignette can illustrate this point.

A 38-year-old patient suffering from chronic paranoid schizophrenia was referred to consultation liaison psychiatry after his refusal to continue palliative treatment of a testicular cancer, known to respond to chemotherapy. Upon evaluation, the patient appeared competent with regard to medical treatment decisions; he understood the situation, knew the treatment options and their outcomes and explained his refusal to continue treatment by the fact that each treatment and contact with the medical staff was associated with unbearable anxiety, despite an adequate psychopharmacological treatment. He had informed his son, a teenager, that he would not accept any further treatment, that he knew that he would die of the disease in the near future and told him how much he loved him and how sad he was of not having been able to share these feelings with him because of his mental illness. In conclusion, he told the psychiatrist, "You know doctor, I prefer to die physically than go through hell mentally again ...".

While other patients may be ready to pay a heavy physical and psychological price to prolong their lives, this patient clearly indicated that for him psychological suffering has reached its limits. After an in-depth discussion, his wish was respected and he was comforted in his decision.

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