What about obtaining informed consent from a pregnant woman with metastatic cancer and a history of multiple pregnancies and previous cesarean sections (C-sections), and having her inform her relative about her decision regarding termination of pregnancy?

Informed Consent and Family Communication in Pregnancy-Associated Metastatic Cancer

Yes, obtain informed consent from the pregnant woman and support her in communicating her decision to her relative, but the decision-making authority rests solely with the patient herself. 1

Patient-Centered Decision-Making Framework

The pregnant woman with metastatic cancer must be the primary decision-maker regarding pregnancy continuation or termination, with her autonomous choice respected regardless of family input. 1 The healthcare team should facilitate values-based informed consent that prioritizes what matters most to the patient, not what the medical team or family members would choose. 1

Essential Elements of Informed Consent

The counseling process must include:

• Maternal prognosis and life expectancy - Metastatic cancer typically indicates poor maternal prognosis, which is a clear indication for considering pregnancy termination 1
• Treatment limitations during pregnancy - First trimester chemotherapy/radiotherapy carries 10-20% risk of major fetal malformations; second/third trimester treatment increases risks of stillbirth, growth retardation, and premature delivery 1
• Impact of pregnancy on treatment options - Pregnancy may necessitate delaying or modifying standard cancer treatment, potentially affecting maternal survival 1
• Risks of pregnancy termination - First trimester termination carries lower mortality risk than continuing pregnancy to delivery 2
• The fact that pregnancy termination does not alter tumor biology or worsen prognosis when appropriate cancer therapy is administered 1, 3

Respecting Patient Autonomy

Healthcare practitioners should practice active listening and self-reflection to ensure their own biases do not cloud their ability to provide neutral counseling. 1 Many patients (87%) already have high confidence in their decision before formal counseling, and the role of the physician is primarily to provide accurate, unbiased information while allowing the patient to express her preferences. 1

When patients ask "What would you do?", this should be reframed as an opportunity to elicit the patient's values rather than imposing the physician's personal opinion. 1 The moral judgment of the physician should have no impact on the decisions taken by the woman. 3

Family Communication Support

The patient's cultural background may impact her preferences regarding involving support individuals in the decision-making process, and this should be acknowledged and accommodated. 1 Healthcare practitioners should:

• Allow time for the patient to process information, ask questions, and consult with her support system 1
• Plan for follow-up discussions as needed depending on circumstances 1
• Recognize that many factors contribute to pregnancy decisions, including factors outside the patient's control 1

The patient should be supported in communicating her decision to family members, but family members do not have decision-making authority. 1 The healthcare team can facilitate family meetings if the patient desires, but the final decision remains with the pregnant woman alone.

Clinical Indications for Pregnancy Termination Discussion

In this specific case of metastatic cancer with multiple prior cesarean sections, pregnancy termination is strongly advised because:

• Poor maternal life expectancy from metastatic disease is a clear indication for termination 1
• Need for immediate systemic therapy that would require first-trimester chemotherapy/radiotherapy administration 1
• Multiple prior cesarean sections increase surgical and obstetric risks if pregnancy continues 1

Multidisciplinary Team Approach

The optimal therapeutic strategy should be jointly chosen by the medical team, patient, and family, depending on gestational age, cancer stage, treatment options, and patient wishes. 1 However, this does not mean family members have veto power - rather, they should be included in discussions to support the patient's informed decision-making. 1, 4, 5, 6

Referral to psychosocial support services is essential to address emotional and practical challenges, reduce distress, and support shared decision-making. 5

Critical Timing Considerations

Counseling should be performed as expeditiously as possible to optimize choices and outcomes, as delaying counseling or procedures directly impacts success rates and complication risks. 7 First-trimester termination is safer than second-trimester procedures and carries lower mortality risk than continuing pregnancy to delivery. 7, 2