I walked into her hospital room, and found a frail, confused 89 year old lady, who thought she was in her home, waiting for her (deceased) husband to come home. Her distraught adult children sat on the sofa, waiting for the oncologist to advise them on the next step. She had been noted to have a persistent cough for a few months, and had slowly dropped her weight and functional state. She had gone from being fully mobile a few months ago, to being confused and dependent on people to take her to the dining hall at the retirement home where she lived.

Her family took her to her primary care doctor, and a chest x-ray, and then a CT scan showed some shadows in her lung, and in the lining surrounding the lung. First, she had a biopsy under CT scan guidance, which didn’t yield an answer. Then she had a mini operation, which inserted a camera between the ribs, into the lining of the lungs, to extract some tissue for diagnosis. This had been unsuccessful in establishing a diagnosis as well. Now she had been admitted to the hospital with increasing weakness and confusion.

Her admitting team didn’t know which direction to take next. That is when I entered the picture. While I gathered information from her children, I sat on her bed, and held her hand. And as I presented the options, I thought I should present the one that had not been suggested yet. Everyone else had been barreling down the path of more tests to pursue a diagnosis, and I suggested stepping back and asking the question, why?

Will finding the diagnosis do anything for her? She’s frail, and 89 years old. Another attempt diagnosis would involve an operative intervention. A third attempt may yield a diagnosis of cancer, which is really what we suspected. Then what? The involvement of the lining of the lung, and her age precluded surgery and radiation. Again, given her age, and functional status, she wouldn’t really be able to undergo chemotherapy. Chemotherapy would not be curative, and may not be a fruitful exercise.

The son and daughter were very upset. “How do you know it IS cancer?”

“We don’t, but it points in that direction. But it can certainly be pursued with another procedure to establish the diagnosis. There is a risk of developing an air leak, postoperatively, and needing a chest tube for drainage. If getting the diagnosis helps her live longer or better, then it is worthwhile. But if it does not, then we may be putting her at risk for no good reason.”

“How long do you think she has?”

“Well, if she has lung cancer, and it’s Stage 4, it depends on how fast it is growing. Untreated, if it is fast growing, then the life expectancy can be in the range of 6 months. If it is slow growing, she can live for up to 2 years. In that time, we can take care of her any of her symptomatic needs, pain management, nutritional support, and make sure she is comfortable.”

The children were very upset. I suggested that they should think about their options; they could let the team know about their wishes when they came to a decision. I walked away from this encounter an hour later, feeling that we had had a meaningful discussion. I handed over the baton to my colleague, to follow up the next week.

As it turns out, she did have another surgical procedure. Fortunately, she did not have a complication. Unfortunately, she did have a malignancy of the lining, called a mesothelioma. In the end, she could not be treated with any treatment, and was discharged back to the nursing home for care and comfort measures.

What is the right thing to do, and whose interests are we serving? Is this lady, or anyone better off getting a diagnosis?  I can understand that a distraught family does not process what they are hearing. Families can demand futile interventions and some physicians do not have fortitude to withstand such pressures.

My concern for the future of the American medical system is that none of the well connected and well regarded physicians advising this family thought it appropriate to stop intervention.  And this is not good care for our sick and elderly patients.