Weeks before major surgery, a patient in his mid-80s cancelled an appointment with a geriatric oncology service, calling it unnecessary. An astute nurse convinced him to attend. The patient had been diagnosed with an early cancer. The surgeon said surgery was the only cure but, noting no urgency, sent him to see Dr Ranjana Srivastava.
What matters most
Dr Srivastava asked the patient to describe his day. Each morning he tended the garden, had coffee with old friends, and returned home with fresh salad leaves for his daughter-in-law. After dinner, sometimes with grandchildren, he retired early. His son added that his father's memory was beginning to falter but an established routine kept him functional. Both praised his quality of life as ideal.
“I just want it gone,” the patient said of the cancer. Dr Srivastava explained that the risk of complications was high – even reversible events such as delirium, infection and electrolyte imbalance could cause prolonged difficulties. “Patients often worry about ‘dying on the table’ but that’s rare – it’s the aftermath that matters.” She and the surgeon estimated the cancer was unlikely to cause problems during his lifetime.
The patient had tuned out. “I know you’re tired, so here’s a simple question,” Dr Srivastava said. “At this point in your life, what matters to you?” His face lit up: “Meeting my friends. And buying salad leaves for my daughter-in-law.” The son was visibly surprised. When asked what if he could no longer do that independently, the patient replied: “Then it’s not a life I would want.”
The turning point
This articulation became the turning point. The patient later cancelled surgery. The explanation: making a fast initial decision had relieved the distress of indecision, but once he had voiced what mattered to him, the right decision was clear.
Dr Srivastava recalled this encounter after hearing a talk on shared decision-making. At its simplest, this involves the doctor bringing medical knowledge and the patient contributing personal preferences to reach a collaborative decision. But far too often, patients report not understanding that they have a real choice, including saying no. This leads to decisional regret.
Challenges and tools
One challenge is language: words like rare, likely and tolerable are subjective. Another is time: pressed doctors can speed through a list of risks and say, “Sign here.” A third is a knowledge gap – shared decision-making must be explicitly taught. A recommendation should include scientific evidence and a deliberate discussion of the pros and cons for that patient with those goals.
An Australian website, spearheaded by a geriatrician, contains a plain-language guide designed with patients. A one-page “before your appointment” sheet lists questions every patient should consider. Another useful site comes from the NHS. For an ageing population, shared decision-making must go from idea to reality. The tools are free; if patients insist on using them, doctors will follow.
