Anemia II

This is a continuation of the previous post (scroll down). A quick apology for the delayed blogs - I always seem to exceed my self-allotted time for writing.

With regards to the longstanding anemia, this 80 year old woman had repeatedly declined colonoscopy. She understood the risks and benefits - and our suspicion that her anemia was due to colorectal cancer - yet still declined. She didn't have incredibly persuasive reasoning, just that she didn't want it. She said that her parents died of old age, and she wanted to die of old age as well - a feat that is incredibly hard to do in today's era of modern medicine. "As long as I'm not in pain, I'm fine. I don't need to know why my blood counts are low. I just want you to give me my transfusion and send me on my way."

Most medical practitioners would not be comfortable with such a statement. For us, why someone has anemia is fundamentally important. After all, transfusions are not a risk-free or cheap intervention and if we can prevent the anemia, then we can eliminate the need for transfusion. Furthermore, our suspicion was high for cancer and as doctors, we want to find out and intervene. Cancer is one of those things that gets our hearts going; we need to get it before its too late.

During this hospitalization, I again offered colonoscopy, and she again declined. But when on physical exam I found a large spleen, I told her that we would like to do an abdominal ultrasound. I would like to say I offered this to her, but you know how doctors (even second month residents) can be: I probably said, "You feel this mass in your belly, right? We'd like to take a picture of it with an ultrasound machine - similar to the kind they use in pregnancy. It won't hurt. That's okay, right?" Certainly, she could have said no, but I didn't dwell too long on it - after all, an ultrasound is minimally invasive.

The ultrasound found spleen and liver masses. A CT followed, then a PET scan, until we were at a real crossroads. We wanted a biopsy; we wanted tissue. Was this lymphoma? Metastatic carcinoma? Disseminated infection? Something else? But she - and I expected this from talking to her - simply wanted to go home. She had received her transfusions and felt better. As far as she was concerned, our care was excellent but overboard. She never really asked for all the imaging studies and was nonplussed by what we found.

"I'm not in pain. You say there are these lesions in the liver and spleen, and that's fine. They're not bothering me. I'd like to go home. I want to play my clarinet. I want to be with my grandsons. I'm feeling perfect after those transfusions. Thank you." We pressed her. "Yes," she said, "I know you think it is cancer. I know it'll probably kill me. I'm 80. I'm okay with that."

So we sent her on her way with an appointment with her primary care doctor to follow up on this potential malignancy. But the resident and I had our reservations. Had we done too much? Did she really need that ultrasound and CT and PET? All of the things we were doing were things we wanted to do, but were they really consistent with her goals of care?

To be honest, I felt that we hadn't been completely ethically sound there. Of course, we cannot force anyone to do anything they don't want to do, and we hadn't here. But doctors are very skewed creatures. We're biased. We see an abnormal finding, and we want to know what it is. We need to know if we can treat it, even if that involves toxic chemotherapy. And when a patient tells us she wants to die of old age and doesn't need to know, it clashes with our frame of reference. We start wondering whether the patient is really competent and then labeling them as "difficult."

But here, the patient was completely right. Her goals with regard to health care were simple: keep me symptom free. Do no harm. Whatever she has will kill her. She's okay not knowing. She's okay dying of "old age." We not only have to accept that but support her wholeheartedly in attaining that goal.