Thursday, June 4, 2009
I received a consult one morning on an old guy, ostensibly for "abdominal pain". It was early, before 7:30 and no one had seen him yet. The internist had admitted him over the phone from the ER. I walked into the room and I saw a ninety year old, 100 pound guy who glowed yellow. He looked skeletal. His skin was paper thin, like cellophane wrapped around a chicken breast. He was affable enough. He knew where he was. He said his stomach had been hurting him for months. He'd lost close to fifty pounds since Christmas. He lived alone in an assisted living facility. He had a son in Alabama, but that was it.
I read through the chart. His bilirubin was 8 and the rest of his liver function tests were wildly abnormal. His Ca19-9 was over 20,000. A CT scan had been done at 3AM but there wasn't a read on it yet. I looked at it myself and easily identified a giant mid body pancreatic mass with multiple liver mets. I wrote a note about the findings and recommended a hospice consult.
The next day, I didn't make rounds on him until late, close to 7pm. In the interval, an astounding amount of medicine had been practiced. Consults had gone out to GI, oncology, and nephrology (creatinine 1.9). The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.
I stared at the chart for a while. I was a little tired and foggy brained. But I couldn't believe it. The poor guy was zonked out in his bed, exhausted from all the tests and procedures that had been administered that day. I wrote in the chart something along the lines of "further invasive procedures/chemotherapy would be ill-advised" and I strongly encouraged a hospice consult. (I may or may not have capitalized and triple underlined the word hospice.)
The next day, the dogs were called off. The son arrived from Alabama. They had decided to forego any further treatment. He would take his Dad home....