Robert Larsen - Patient-centered Ethics: Pathography

Jul 16, 2022 at 04:00 pm by pj

During my time on my internal medicine rotation, I spent a lot of time working with cancer patients. Some patients had cancers that were responding well to chemotherapy and radiation while others underwent massive surgeries in order to cure their disease. These patients seemed to always be in good spirits and were optimistic about their chance for survival. On the other end of the spectrum, we also cared for patients with terminal diagnoses, and these patients were always a challenge, both medically and psychologically. One patient in particular stood out to me as we rounded on our daily patients. Her name was SJ and she was a 45 year old woman who had been diagnosed with adenocarcinoma of the lung which had metastasized to her liver and brain.

SJ was admitted to our service about 3 weeks into my rotation. She had been admitted to the ED earlier in the week because she was complaining of a chronic cough that was not responding to over the counter remedies, worsening shortness of breath, and weight loss. She had gradually noticed these symptoms over the past 6 months but didn’t really think much of them. She finally decided to get checked out because she was starting to get short of breath just walking around her house and doing chores. She does not have a primary care physician, so her best option was to go to the ED. She underwent a CT scan which showed a large peripheral mass with a massive pleural effusion surrounding her left lung. There were also numerous suspicious lesions identified in her liver at this time. Her pleural effusion was drained, collecting nearly a literal of fluid which was sent off for testing, and biopsies were taken of her lung and liver lesions. All testing came back with a horrific diagnosis of metastatic adenocarcinoma.

She was one of the first patients we saw during our morning rounds the day after she was diagnosed. We had read all of the notes and reviewed all of the imaging, lab work, and pathology. We prepared ourselves as best we could, but even a seasoned hospitalist like my attending was feeling the effects of the inevitable conversation to come. As you might imagine, this diagnosis caused her world to stop. She was stunned, shocked, confused, sad, angry, and terrified all at the same time. She wanted to know how this could have happened to her. She had never smoked and was never around anybody that smoked. There was no history of lung cancer in her family, or any cancer for that matter. She had a husband and two children who she needed to look after. We listened to her intently and tried to answer all of her questions as best we could and spent a good portion of our morning with her. It was a sad case and we wanted to make sure that all of her questions were answered and try to instill a bit of optimism in her spirits. She cried several times through the interview and cursed the world for not being fair, but by the time we were ready to leave she seemed satisfied with what we had discussed.

Despite all that she was dealing with, SJ remained resilient and optimistic that she could fight this disease and win. Her husband and children came to visit often and they always seemed to have a positive effect on her attitude as they were a constant reminder of what she was fighting for. She was started on chemotherapy shortly after being admitted, which further lifted her spirits as she was finally receiving treatment for her cancer. The weight of her diagnosis rested heavy on her head, as it was the usual topic of conversation during our daily rounds with her. Her main worry was about what would happen to her family if she could not win the fight. Thoughts like this often kept her up at night, so she never slept really well and was always tired during our talks.

As the days and weeks progressed while she was on our service, she unfortunately continued to decline. Her breathing was always labored when we examined her and she had to use a nasal cannula at all times just to keep from getting too short of breath while at rest. Her pleural effusion would re-collect every few days, each time requiring interventional radiology to drain the fluid. She was not responding well to her chemotherapy and her disease was starting to slowly take over. One morning during the last week of my rotation, we entered SJ’s room to begin our usual conversation, but something was different. SJ was confused and couldn’t speak very well. She was having trouble articulating her words and was falling asleep during the interview. My attending and I both knew something was wrong, so we continued to investigate. After a thorough physical exam, my attending was worried that SJ had had a stroke, so he ordered a brain MRI to assess the damage. When the results came back, it showed a large portion of ischemic tissue on the left hemisphere as well as more suspicious metastatic lesions. Not only did she have a stroke that she would have a hard time recovering from, the cancer had spread to her brain. We informed the family of the horrific news and began the process of setting up palliative and hospice care so that she could remain comfortable.

Unfortunately I am not sure what ultimately happened to SJ as my rotation ended and I was never able to follow up with her case. However, I will carry all of the different encounters with me as I progress through my career as I will never forget her case. Every day involved a different challenge, both with her medical care and navigating through the psychosocial aspect of her disease. She helped me understand her perspective by sharing her thoughts about her disease and the care she was receiving without hesitation, even if it was difficult and uncomfortable for her to discuss. Even though it wasn’t always apparent, she had a strong understanding of her prognosis, and towards the end had started to accept her fate. Although I will never be able to fully empathize with what SJ went through for those few weeks (how could I, I have never been on my death bed before), I do believe that through all of my interactions with her I grew as a provider who can at least understand and sympathize with a patient in her position. I learned how to listen to her and take her thoughts into account as well as provide the best care possible for a terminally ill patient and continue to treat them in a humanistic manner. I will never forget my encounter with SJ as her experience alone has helped me grow as a provider who will continue to empathize with patients and always try and take their perspective into account when caring for them.