TERMINALLY ILL PATIENT:
Dear Sumner:
I would like you to see Harry, a 68 year old patient of mine who was diagnosed with renal cancer about 5 years ago. He underwent a radical nephrectomy shortly after the lesion was discovered. He has had no recent weight loss and currently has no symptoms suggestive of recurrent tumor. However, a routine chest X-ray done a few days ago revealed obvious metastatic lesions. Blood chemistries are consistent with spread of the tumor into the liver. These came as quite a shock to both him and his family, since they had been reassured by his previous urologist that the tumor had been completely removed. Needless to say, some active steps should be taken to handle this very distressing situation. Although Harry, himself, is currently in no dire distress, given the radiological and serological findings, we are likely dealing with a non-curable process that will likely manifest itself clinically in the very near future. I and the family will be most grateful for your input.
Dear Bill:
I had a very frank discussion with Harry and his family about the various aspects of kidney tumors. It was interesting to note Harry’s attitude shift from one of anger and total dismay to one of relative calm as he gradually came to grips with his own disease process. (Of course, it would have been a better situation if Harry as well as his family would have already anticipated the possible happenstance of metastatic/terminal disease before this state actually occurred, but unfortunately, this was not the case here.) Harry asked some very thoughtful and practical questions about possible scenarios involving metastatic disease. We spoke quite openly about the potential conflicts involving the issues of quality versus quantity of life and the fact that medical technology today has awesome capabilities of prolonging life. Harry expressed his preferences regarding the future management of his care, stating quite emphatically that he wanted neither to have his life prolonged by artificial means, nor to suffer with severe pains. I think it was also very helpful for Harry to have his family in on the discussion as he came to grips with his current condition.( This can really help avoid future feelings of guilt if family members feel that insufficient steps are being taken to prolong the patient’s life.) Harry and his family agreed that as his physical condition deteriorated, Hospice care would be initiated.
