What would you do if this was your parent? I honestly don’t know

Yesterday I saw a 90-year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest x-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.

As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.

A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90-year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries

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  • http://twitter.com/MedicalGirl Lori

    Should the PET-CT been ordered after the original CT was inconclusive?

    • Miranda Fielding

      Probably. But it was also reasonable to wait, repeat the CT since she was asymptomatic, and then make a decision, which her doctors did.

      • Suzi Q 38

        My aunt is 99. She will be 100 July 4, 2013.
        She never had any children and her husband died 20 years ago.

        About 3 years ago, she had a heart attack and her doctors were talking about putting in a shunt. She refused and said that she wanted to go home. I remember the doctor telling me that she might die. I told my aunt: “Auntie, he says you might die if you don’t have it put in…what do you want to do?”

        She said that she didn’t want it, as she felt too fragile to recover from the procedure at her age (97). I told her to tell the doctors what she decided.
        She came home, recovered well and is doing great.

        We just had to take away her driver’s license due to glaucoma.
        She was so mad.

        We feel so lucky to still have her with us.

  • weakanddizzy

    ” All I want is another ten years”. That is the crux of the issue. As a society we have unreasonable expectations. If she was my mother or my wife I would want her to live at least as long. The problem is that we have no idea if we are going to help her or hurt her. She believes we are going to extend her life by being aggressive. As a physician I know there is a significant risk that we will unintentionally harm her by being aggressive, likely decrease the quality of whatever time she has left and increase the cost to the taxpayers. A difficult situation all around by well intentioned patients and providers.

  • http://www.facebook.com/profile.php?id=853905000 Mick Kerr

    I think it comes down to interpreting her wishes, risks, probability, and managing all three, all the while remaining cognisant of her age. She wants to live longer. Fair enough. I’d humbly interpret that as, she wants to go with whatever option affords her with the longest quality of life possible. On one side of the equation is living with the uncertainty of an undiagnosed cancer, and the chance that this might either significantly reduce her remaining time, or reduce its quality. However you’d avoid the possibility of diagnostic and interventional complications. On the other side is the wager that we might be able to intervene, with the aim to cure, or at least prolong and preserve her life and quality of the same. As alluded to though, this itself brings the risks of intervention and diagnostic procedures.

    It would be nice to know things like the likely diagnoses / likely pathology, the prognosis in terms of disease progression / survival rates etc for these, the appropriate diagnostic pathway and modalities, their respective sensitivities / specificities / costs / and invasiveness.

    If it was able to be reduced to probabilities with some fancy algebra, eventually boiling down to something like option A will give you a 60% change of a better and longer life, and options B will give you a 40% chance, it’d be an easy choice then.

    If that was the case, then things like IBM’s Wilson would actually do what they reckon and replace physicians.

    It’s taking that knowledge, balancing those probabilities, and then applying that to and with each individual patient and their circumstances that makes a physician. At least in my humble and under experienced opinion.

    In answer to the question… Buggered if i’d know. Sounds like there’s going to be lots of communication happening regardless of the outcome.

  • Suzi Q 38

    I think that I would ask my mother what SHE wanted.
    You did, and you have your answer.
    If she has insurance and/or medicare, so be it.
    She may change her mind. I would be flat out direct about her prognosis.
    My MIL had lung cancer, and she went through everything, only to die within 3 months. By the time her cancer was discovered, she had mets to the brain.
    She was only 61 when she died. Too young for medicare.

    After watching her go, I think if it were me I would order a plane ticket to a tropical island instead. I can think of better things to do with my last days.

    On the other hand, everyone is different. we have the right to do what we want when we are sick.

  • Miranda Fielding

    Thank you all for your thoughtful comments. My patient did indeed go on to have a PET CT last week. The small area of abnormality in her left lung was strongly positive. The only other abnormality on PET was a 3 cm area of markedly increased uptake in her sigmoid colon. Her last colonoscopy was in 2005. After discussion with her primary care MD and her pulmonologist, she has decided to undergo bronchoscopy and biopsy of her lung lesion, and a sigmoidoscopy has also been scheduled. Are we saving her life by discovering an early stage lung cancer and an equally early stage sigmoid cancer before she bleeds or obstructs? Or are we leading her down the path to complications from procedures that may in and of themselves harm her? I will give you follow up. Miranda

    • Suzi Q 38

      Yes, your last two sentences say it all: “Are we saving her life by…..
      or are we leading her down……harm her?
      You may be “waking up” a sleeping giant. Given her age, and overall health, I would be hesitant.

      If possible, I would call all of my children and grandchildren and go rent a condo or beach house in Maui instead. If I felt well enough to continue, my DH and I would probably hit Tahiti or New zealand.
      Tokyo would be too busy and stressful.

      Feet feeling the wet sand, a beach chair, no sunscreen, and eating anything I wanted to eat….a few mai tais.

    • Mike C.

      I would take comfort in the fact she is still competent and able to decide for herself how her care proceeds, as long as you inform her of the options, risks, etc and consequently provide the best care she chooses you should be satisfied by whatever outcome.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Ten years is probably kind of an unreasonable expectation. And I would want ten years too IF IT WOULD BE THE SAME QUALITY OF LIFE. But it won’t be. Lung cancer treatment is no picnic. I don’t think she really gets what’s going to be involved and how sick she could get. I would advise her to get on a plane to Cancun. People can be intelligent, sharp, and able to comprehend and still not know what they’re getting into.

    • Molly_Rn

      What a great answer: get on a plane to Cancun. In other words enjoy your life now while you can. Live joyously and with no looking back. In fact we can’t guarantee anyone
      ten years….no one can.

  • Mike C.

    If this was my parent I would continue to let her make her own choices and as a doctor to continue to provide the best care possible based upon those choices while informing her of the benefits and risk of all options. :D

  • http://www.facebook.com/people/Tom-Fitzsimmons/1405121136 Tom Fitzsimmons

    Did it occur to you that she could have a fungal infection? Check the absorption times during the PET scan. The fungus feeds consistently, a tumor has it’s more and less active times. It’s easy to differentiate and all documented. I believe the fungus of interest is Pseudo-Cocci. or something similar to that.

    • Miranda Fielding

      Thanks Tom. That was considered. The PET lit up, and so she is going to bronchoscopy and fungal cultures will be taken. Appreciate your input.

  • http://twitter.com/lactmama Evi Adams

    There are 90 year olds and there are 90 year olds. I know a few 100 year olds who would be insulted if their wishes were not considered. This woman and her husband are intelligent beings who know how they think and feel. Once you hit 90 in good condition you have a good chance of having those extra ten years. The medical community needs to rethink their stereotypes of aging. Doctors usually see sick people, babies to geriatrics. They do not always know too much about the healthy ones.

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