M E N T O R

which do you decide to take?
Cancer patients have been exposed to this
dilemma more than the regular person,
and their treatment is shaped around it.
Chemotherapy is the use of cytotoxic drugs
to target cancer cells. They kill cells very effectively,
but are not so good at distinguishing
cancer from normal tissue and this can
lead to some serious side effects: fatigue, for
example. Tiredness can take over your life
and last for months after the treatment has
finished. Your quality of life is on the line
when you cannot continue to do the activities
that define you as you. When that is the
situation you are faced with, when you are
too tired to seek any enjoyment from life,
which option have you really chosen? Other
rapidly dividing cells such as your hair can
be badly affected, leading to a change in appearance.
This can be horrifying for women
or younger patients as they stand out from
their peers, or feel stripped of who they are.
Maintaining self-esteem is vital, right to the
end of life, in order to go on living the life
you want to lead.
When reading ‘The Other Side’ by Kate
Granger, what struck me as harshly unfair
was the lack of choice the patient (who was
also a physician) had. She had been unintentionally
tasked with making the decision
of prolonging her life or prolonging
her living. After initially deciding to try to
squeeze out all of the extra days she could,
her final decision was to go with the latter,
something I consider a brave choice. It is
not a choice isolated to the patient at hand,
it affects other sick people too. By opting for
palliative care, you usually free up an extra
hospital bed as most of your treatment can
be done at home, leading to better care for
others. Additionally, attempting curative
treatments and further investigations tends
to be significantly more expensive than palliative
care. Those funds can be redirected
to someone with a more positive prognosis,
or that slot in the CT scanner can be used
in an emergency. This is not a case of martyrdom,
nor is it supposed to encourage patients
to give up the fight so that someone
else can have a shot – it is about accepting
when the battle is lost, and moving on.
These reasons are partly why I believe
to prolong living should be a priority. Of
course, how can I, or anyone, put myself
in the position of a cancer patient? It may
seem unfair to spout these beliefs, however I
hope these ideas may help put an important
decision in perspective for others that need
to decide.
In fact, people who do not have a terminal
diagnosis are making these kinds of decisions
for us on a daily basis. QALYs (quality
adjusted life years) are used to determine
the economic benefit of a medical interven-
Think NICE are getting it wrong?
Have a go at
working out QALYs
These may not be your goals, but you must have a purpose,
whatever it is, in order to meet the definition of living: ‘the pursuit
of a lifestyle of a specified type’. It is not enough to spend
your days without aim; we talk about a person’s raison d’être for
good reason.
tion. They allow healthcare funding bodies
such as NICE (National Institute for Health
and Care Excellence) to weigh the benefits
and drawbacks of permitting certain procedures,
or prescribing certain drugs. A price
tag is attached to each year of life saved by
a treatment, and this is amended depending
on the quality of that year (for instance, a
year spent in constant pain is not equal to
a year spent in perfect health). A problem
associated with the use of QALYs is that
they are ultimately assessing the economic
benefit of certain interventions, which fails
to take into account every personal factor
and whether intervention would be in the
interest of prolonging living or prolonging
life. What do I mean by this? Well, if a patient
only ever has one year left to live, and
a treatment would give them near perfect
health for that time, the intervention is still
only going to be worth one QALY. Technically,
a treatment which provides someone
with 20 years left to live, but at only at half
perfect health, is worth ten times the first
treatment. In effect, we are saying the second
patient is worth ten times more.
Fortunately, NICE does not have to directly
choose between two treatments in this way.
They have come up with figures that are
used to determine the viability of intervention,
with any treatment costing less than
£20,000 per QALY as ‘cost-effective’ and
£20-30,000 approved so long as certain criteria
are met.
The problem is still a real one, though, and
it is illustrated perfectly in a documentary
by Adam Wishart. It uses the case of patients
with multiple myeloma to explain
why QALYs disadvantage the terminally ill.
The drug in question was Revlimid, which
would be extremely beneficial in prolonging
living. It saw enormous symptomatic improvement
in a number of patients at trial,
but only increased their lifespan by months
or maybe a handful of years.
There is a lot more to this debate than can
be fit into one article. It is possible people
would never reach a consensus, given all of
the facts and all of the time in the world.
Perhaps no one can truly understand the
magnitude of this decision until they are going
through it themselves. The GMC makes
it clear that it is a doctor’s duty to show
respect for any life, so surely fulfilling this
respect requires allowing patients to continue
or start any treatment that will enhance
their ability to live. In saying this, there are
measures put in place to ensure that every
patient can still live in comfort and with
support. Palliative care provides a truly dignified
end to the dying, whether they are old
or young, active, or bed bound and allows
families to spend quality time together for
months or years before the end. If I were
asked to say what it means to prolong living
in one sentence, my response would be to
live life with intention and meaning, and to
make the most of every situation.
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