Living Life in the Hot and Cold State Part 2: Medical Implications

Humans live in a hot and cold state as well as in-between. This applies not only to economic situations, as I wrote about in a previous column, but medical as well. It is the extremes that we consider here.

During the “hot” state, decision-makers are emotional though they frequently do not recognize it. In this condition, they fail to appreciate that their feelings influence their decisions to the magnitude that they do. Further, when the “hot” state turns to a “cold” state and the decision maker is no longer biased by emotion, there is little insight into the earlier “hot” state.

Roger Lowenstein explores these concepts in regard to patient medical decisions in his seminal paper entitled, “Hot-Cold Empathy Gaps and Medical Decision Making.” He makes the point that patient decisions can revolve around emotions including fear, pain, discomfort, and anxiety as well as others. Though these sentiments may not persist over time, if they are present when major medical and end of life decisions are made, they can and will influence the outcome. Thus, the “hot” state decision can influence the “cold” state condition that may exist later and during which a different choice might be made.

One example is a patient’s selection in his treatment for prostate cancer. Though it is known that surgical treatment of contained prostate cancer does not produce mortality benefits, many men chose it, apparently to relieve their own anxiety about the presence of the cancer in his body. This is in spite of the fact that a more conservative approach would be better.

This choice is made because the patient is told he has prostate cancer and then is asked to choose a therapy shortly thereafter. At that sensitive time, he is fearful and can only think of ridding himself of the offending malignancy. If he were asked several months or more after receiving his diagnosis, his decision could well be different, especially if he considers the potential complications of the surgery. Lowenstein says, “This is because people tend to overreact to risks that are new and unfamiliar…”

End-of-life decisions too are influenced by the “hot-cold” state. In one study 168 cancer patients graded themselves two times per day on pain, nausea, appetite, activity, drowsiness, sense of well-being, depression, anxiety, and will to live. Over 12 hours, the will-to-live score fluctuated 30% plus. This variation related directly to marks in the other areas: if they were negative, there was little will to live; if they were positive, the patient wanted to live. In other words, we make important end-of-life decisions depending on how we feel at the time. The immediacy of feelings is more important to the patient than the overall picture. Lowenstein suggests that physician intervention may be helpful here. He says:

“…patients, and possibly their families may not be in the best position to make decisions when they are in affectively aroused states that are unlikely to last. In some situation, the more dispassionate perspective of a physician may provide a more stable basis for decision making and lead to decisions that are more consistent with the long-term interests of the patient.”

My take on all of this is that we are making progress in patient care in areas that weren’t even conceived of 20 years ago. Soon, taking care of the sick will mean understanding not only medicine as it is now, but also neuropsychology and how it relates to decisions made by patients and physicians about medical care.