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Case history

image A 69-year-old man presented with a short history of dysphagia. His medical history included a leg angioplasty, hypercholesterolaemia and atrial fibrillation. He took clopidogrel, rivaroxaban and gabapentin. He was a smoker and a moderate drinker, and ran a busy domestic cleaning service. Investigations confirmed moderately differentiated invasive adenocarcinoma of the oesophagus on a background of Barrett's oesophagus. CT staging was T3N1M0. The upper gastrointestinal multidisciplinary team (MDT) recommended neoadjuvant chemotherapy followed by curative surgery.

The patient attended the medical oncology clinic with his wife to go through the treatment plan. As ours is a cancer unit in a district general hospital, only chemotherapy is given locally and the surgery is performed in a tertiary care centre in central London. Radiotherapy is given in a cancer centre about 25 miles away.

Despite a good chance of cure, he declined the plan with surgery because he did not like going to central London. He also refused to go to other centres because of the distance. He wanted to take only chemotherapy that was given locally. Definitive chemoradiotherapy (dCRT) was offered as an alternative for a better result. After knowing the duration and daily commuting for radiotherapy, chemotherapy schedules and potential side effects, he declined all treatments because he was concerned that he would not be able to serve his customers due to the time commitment and side effects. He denied financial reasons for his decision. Although it was made explicit to him that he could die prematurely from this cancer if left untreated, he was adamant that he did not want to miss serving his customers and preferred to let 'what will be will be'. His wife, the clinical nurse specialist and the consultant all agreed that he had full mental capacity and understood the seriousness of the condition and the consequences of not having treatments.

The clinical nurse specialist continued supporting him by phone. Two weeks later, as his dysphagia got slightly worse, he agreed, and eventually took, a full course of chemoradiotherapy (50 Gy in 25 fractions, with weekly carboplatin and paclitaxel). A PET-CT scan done at 12 weeks after completion of the treatment showed no definite recurrence.

What could be done if he continues refusing treatment?

By not having the curative surgical approach recommended by the MDT, how could his prognosis be affected?

How should he be followed up for best outcome taking into account his commitment to his work?

What could be done if he continues refusing treatment?

Some patients make decisions about a treatment based on their personal values, experience and circumstances rather than the side effects and benefits of treatment.1 The General Medical Council's guidance is to respect a competent patient's decision to refuse a treatment even if it seems to be wrong or irrational to others. Anything that may imply judgement of a patient or of his/her beliefs and values should be avoided. The patient may be provided ...

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