Deliberate overdose in the elderly

Professor; and Oncologist, 5 York Street, Oaklands, NSW 2117 gilligan_1 OO@holmail.com Council (NHMRC) guidelines for the management of early breast cancer.! But the higher the rates of compliance the closer those same guidelines could appear to be becoming rules. If guidelines appear to become rules, the right of the patient to make an informed choice may be denied, and that denial could have legal consequences. The right to make an informed choice was highlighted in the Supreme Court of New South Wales. 3 The duty of a practitioner was defined as "A single comprehensive duty covering diagnosis, treatment and the provision of information." The provision of information regarding options in treatment cannot be avoided "No patient, except in an emergency, undergoes treatment without choosing to do SO."3 Specifically, in the NHMRC document, the guideline with regard to adjuvant therapy in node-positive premenopausal women states: In receptor-positive women, ovarian ablation may be considered as an alternative [to combination chemotherapy]. The guideline adopted by Craft et al differed: Women, under the age of 50 years with completely resected axillary lymph node positive breast cancer should receive adjuvant chemotherapy.' All 27 women who fulfilled this criterion received chemotherapy. Is this 100% compliance with the guidelines? Although 81 % of all patients reported were receptor positive, it appears that the choice inherent in the NHMRC guideline was not always considered. Furthermore, 32 of 33 women with tumours greater than 2 cm and with negative or unknown axillary nodal status received adjuvant systemic therapy. For such women, with known negative nodes whose tumour proved to be grade 1, the generally quoted benefit from adjuvant systemic therapy "a 20% reduction in the odds of death"? would increase survival expectation at five years from around 93% to about 95%.4 The Nottingham Prognostic Index" takes grade, size and nodal status into account and allows costs and benefits in the individual case to be refined. A 2% margin of benefit hardly justifies the toxicities and costs of adjuvant systemic therapy, nor would it permit the assumption of its acceptability to all women without involving them in the decision. Guidelines can never determine treatment for each and every patient. Guidelines 8 5 2 13 4 3 2 2 1