One of the down sides of solo practice is not having anyone readily available to act as a sounding board for difficult decisions. On the other hand, one of the up sides of blogging is having the whole world available to help with that function. I have recently worked through a dilemma, and although I believe I am comfortable with my conclusions (as I have reason to believe the patient is, too) I still have this nagging voice in the back of my mind. Preceptors from long ago? Hypothetical partners in a non-existent group practice? Who knows? I'm far beyond actually caring what anyone thinks of me, so it's not pure ego; rather I want to feel more confident that my approach to this situation -- while perhaps different from many others' -- is rational. In fact, what I really feel is that my approach ought to be the norm and not the exception.
I have a lovely 87-year-old lady who has been -- for lack of a better word -- failing, for about ten months. Although she claims to eat well, she has been steadily losing weight. Her memory is slipping as well, qualifying at this point as mild dementia. She complains of an overwhelming fatigue; all she wants to do is sleep. She's always been very active, especially in her garden, so she finds this lassitude quite distressing.
I don't really know what's wrong with her. Chest x-ray and mammogram are negative. Routine blood work is within normal limits. Brain MRI shows chronic ischemic small vessel disease and age-appropriate cortical atrophy; nothing to explain her condition. Upper and lower GI endoscopy were both negative. She hasn't "lost her will to live," a phenomenon I've seen in the past. She doesn't want to die. She's just failing.
I was trying to decide what -- if anything -- to do next. I could send her for a CT of her chest, abdomen and pelvis, looking for an occult malignancy. I thought long and hard about what those scans might show, given that from a cancer standpoint I've already ruled out brain, lung, breast, stomach and colon. Just about any finding I could imagine would require another procedure to confirm a diagnosis (ie, to obtain tissue.) At that point, any diagnosis I could think of (widespread malignancy being the most likely) would either not be amenable to treatment, or would subject her to surgery with or without chemo and/or radiation. She wasn't crazy about any of those options.
Then I considered the risk of kidney shutdown from the IV contrast plus the discomfort of consuming a large volume of oral contrast just to have the scans. Given the truism about what a large percentage of medical expenditures occur at the end of life, would I not also be doing the right thing for society by not even giving her a chance to get stuck in the endless cycle of tests and specialists and more tests? The more I thought about it, the less I was able to justify sending her for a total body CT.
But I don't know what's wrong with her! Isn't it my job to figure that out? Am I being aggressively compassionate...or just lazy?
I know what you're all saying: What does the patient want?
I'll give you her exact words: "I'll do whatever you say."
News flash, all you patients and patient-advocate types: when push comes to shove, most people ask me to make these decisions. In a very real sense, "patient choice" comes down to finding a doctor whose recommendations you can live with. We're the ones with the training and experience, and by and large it is our opinions patients want and deserve. I happen to already have an Advance Directive for this patient in my chart (dated 1993; the standard DNR in case of vegetative state, or -- her words -- "ability to live normally") and in all our discussions during her decline, she's never indicated that she's changed her mind. She is willing to concede this decision to me at this time. Frankly, that means she'd have the scans even though she didn't really want to -- if I thought it was important.
She took a turn for the worse over the weekend. I went out to see her (yes, a house call; on a Saturday night) and after a very long discussion with her and her family, I referred her to hospice. As it happens, she perked up considerably over the next 48 hours. Still, I'm not going to scan her.
So what's the consensus? Am I being prudent and compassionate, or am I just a lazy clinician?