Right now I'm finishing my internal medicine acting internship at University Hospital. I'll never forget a patient I had who was a 48 yo WM with history of metastatic squamous cell lung cancer to the thoracic spine and iliac ala admitted for acute renal failure and a rash secondary to vancomycin toxicity which he was taking to treat a paraspinal abscess. He was a mess. On day two of admission, he left against medical advice because we would not let him smoke (hospital policy) only to come back 3 hours later when he realized he had no place to go. He did have family in town but had a tenuous relathionship with them for reasons I didn't understand. He constantly talked about his fiance from LA who he needed to see. He said she was visiting from out of town and that he needed to see her before any surgery. I was skeptical if this woman was real, and if she was I assumed that she wanted to distance herself from him because of his medical conditions.
During the course of admission, the radiation oncologists and hem-onc doctors determined that there would be no need for aggressive treatments of the cancer at this time. One of the nephrologists nicknamed "the angel of death" for his readiness to withdraw dialysis from terminally ill patients, suggested allowing the patient to leave, smoke, and drink because if we weren't going to treat the cancer, why should we withold the things that make our patient happy in his last few days of life. The neurosurgeons actually wanted to operate on what they believed to be a growing paraspinal abscess, knowing full well how wide spread and aggressive the squamous cell lung cancer had become. We needed an MRI to confirm the CT findings and give us more information as to whether we were dealing with a worsening of the paraspinal abscess, increased metastasis from the lung cancer, or both.
I spent quite a bit of time speaking to other services about what the best plan would be for this patient. However, most of this was irrelevant as the patient had decided that he did not want any surgery at this time and that he needed to go home and "deal with some things" before having a major surgery. So when his kidney function improved, we discharged the patient back to the respite care facility after about a week long admission. On the day of discharge, I sat down with the patient and told him what I knew about his condition. I knew that he didn't have long, maybe 5 months was my guess. I didn't give any sort of timeline for prognosis; I just told him that there is no cure for his squamous cell cancer and even with an operative intervention, we can only expect further progression of the disease. I told him he needed to make plans, talk to loved ones whom he may not see again, because we both knew that he would be back in the hospital soon, and we didn't know how much time was left.
"I hate to be the bearer of bad news."
"Well it's not bad news. It's news. Normally I would write all this down but you explained it pretty good. And your straight with me, for that I thank you. I just feel like I'm sitting in a corner watching as all these doctors make decisions for me and control my life. I just need some time to sort things out, talk to my fiance, and then I'll come back for the surgery."
"I know that it's been a lot to have happen over the course of a few days, and I'm sorry that you have to deal with so much." These were my last words to this patient.
"Well it is what it is, I just gotta go home and sort out my life."
About a week later he did come back to the hospital in acute renal failure, but this time he needed dialysis and was admitted to the ICU in sepsis. His fiance actually did visit him on this admission, and left a note in his chart explaining how the patient did not want to be resuscitated/intubated. At the end of my day when I went to visit the patient, he was nonverbal and groaning, and had the look of someone who had only a few days left.
What I learned from this whole ordeal is that people like to live life on their own terms. No one likes to have decisions made for them, and costly, invasive interventions may be medically indicated, but the patient's wishes need to be addressed early, and they need to be respected. Hospice care should have been discussed with this man early on, but we were hesitant as neurosurgery still wanted to operate which would make the discussion complicated. We kept this man in the hospital for about a week on the medicine service to treat his renal failure and discuss what we needed to do about the paraspinal abscess. In a less litigious and more perfect world, he would have been able to go home on hospital day 2 or 3 so he could talk to his friends and fiance, smoke a few cigarettes, and finish out his life on his own terms.
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