Without relying on clinical evaluation data, how can healthcare professionals do their job of ensuring that patients derive maximum benefit from treatment – or from the absence of treatment? How can sound decisions be made without also taking into account the multitude of personal, familial, sociocultural, physical, emotional or other factors specific to each patient, to each healthcare practitioner, and to each patient-practitioner relationship?

Making healthcare decisions is a balancing act, sometimes a tricky one. After first placing one foot on the limited evaluation data available, care must be taken to keep the other foot from sinking too far into the quicksand of subjectivity or self-delusion. When the data are insubstantial or non-existent, the greater the uncertainty and the trickier the balancing act.

In the field of oncology, for example, what can really be known of the intended and unintended effects, and the gruelling routine of appointments, lab tests and imaging that patients have to go through? And what can really be known of the anxiety caused by repeatedly waiting for results, the anguish of receiving a bad result, or the elation some patients feel after receiving a good result?

How can what is known about the survival data (which may or may not be robust) be balanced against all that is unknown – since such things cannot be quantified – about the joy or sorrow, hope or disappointment, generated by a test result? How to manage the uncertainty of not knowing how, or even if, the absence of a negative change in an "image", at a given moment, will correlate with a longer or better life, or with a diminished quality of life?

Trying to answer these questions is another tricky balancing act. But it can often be a success, when treatment goals are clear. And provided these goals are not limited to their prophylactic, curative, symptomatic or palliative dimension alone. Striving instead, with each patient, to determine the hoped-for tangible benefits, at whatever level, and to identify the potential harms. Clearly distinguishing between considerations based on "science" and those grounded in beliefs or feelings. And steadfastly refusing to engage in lies, denial or avoidance.

©Prescrire 1 April 2022

Source: "Balancing act" Prescrire International 2022; 31 (236): 87. Free

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