0
Editorials: Point and Counterpoint |

Rebuttal From Drs King and Nathan

Christopher S. King, MD, FCCP; Steven D. Nathan, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: S. D. N. is on speaker’s bureaus and advisory boards and has received financial support for research from Roche and Boerhinger Ingelheim. None declared (C. S. K.).

Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA

CORRESPONDENCE TO: Christopher S. King, MD, FCCP, Inova Fairfax Hospital, Advanced Lung Disease and Transplantation Clinic, 3300 Gallows Rd, Falls Church, VA 22042


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(2):278. doi:10.1016/j.chest.2016.04.035
Text Size: A A A
Published online

Extract

We agree with Dr Brown’s philosophical approach, exemplified by his concluding comment that there should be “thoughtful and reasoned discussion between a patient and the physician about hopes and expectations for the future, the goals of treatment, and the risks and benefits of any chosen course.” However, the devil lies in the details of this discussion and how the choice is portrayed to the patient, since the consulting physician’s bias will inevitably influence the patient’s decision. As an example, on one end of the spectrum, the patient can be guided to a “no treatment” choice by the following “we have two new medications; both appear to slow the disease progression in some patients. However, it is uncertain how this might translate to other more meaningful benefits. Both drugs have significant side effects and are very expensive. You would not have been eligible for any of the trials that demonstrated that these drugs worked, so I cannot be sure that either will help you. Do you want to give either of these a try?” Any reasoned patient would likely respond, “heck no” to this preamble. A more favorably predisposed clinician might have a slightly different conversation with the same patient, “You have a disease with an average survival of only 2½ to 4 years. Unfortunately, we are unable to predict the course in individual patients, and even those with well-maintained lung function may have unpredictable precipitous declines. We have two drugs that slow the rate of loss of lung function. We know that patients who lose lung function over time have worse outcomes. Both drugs have some side effects, but not everyone experiences them and they are usually quite manageable. Although your profile does not fit exactly with those patients enrolled in the clinical trials, it is not unreasonable to assume that if they work in selected patients with idiopathic pulmonary fibrosis (IPF), they are likely to work in others as well. Do you want to try one of these?” A possible response to this might be “seems like a no-brainer.”

First Page Preview

View Large
First page PDF preview

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Guidelines
Infant/toddler pulmonary function tests-2008 revision & update.
American Association for Respiratory Care | 4/3/2009
Removal of the endotracheal tube—2007 revision & update.
American Association for Respiratory Care | 8/17/2007
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543