Sunday, February 17, 2019


          There is saying that the Honesty Is the Best Policy , but is  it really true?In life we have incidences where the honest answer may be crude or cruel or not pleasing . In Ganapati ATHARWASHIRSH, it is state the 'I will say Pleasing and Truth'. In personal relationships between the husband and wife and children and friend, this is true.But even in many other aspects of our life we don't have ti lie but we can still say truth without hurting the other person or the relationship.Sometimes we can not tell our boss what we 'feel ' about him or his decisions. We still can say the fact or the truth. In medicine this holds very well. I have come across this on number of occasions. This more often happens when we have a patient who has cancer . This brings me to the today's story.
      I had seen this 75 years old lady who was smoker and had some lung issues . Over course of my follow up she developed a mass in the lung . In all probability it was cancer and so we did do the work up and then i sent her to surgeon  and it was taken out. She did well- had some problem post op. But overall did OK. She needed oxygen after surgery , that was arranged at home . She was doing better and then may be 18 months or so after the surgery , when we did the follow up CT scan she had a mass . We had her see radiation  and oncologist . She had needle biopsy and then the recurrence of the cancer was diagnosed. She had localized mass and so she received radiation. She then saw oncologist , who decided to start her on some chemo . In spite of the chemo she developed new nodules and so the chemo was changed . Now she had multiple nodules in both lungs  and radiation was not option and so she had continued the chemo. She has been old  and has some dementia . She has COPD  and does need some oxygen .She was admitted to hospital with multiple issues , including anemia related to chemotherapy and also had low salt and worsening kidney function and also had swelling of the legs . Further work up showed that she had clot in the legs  and  for some unknown reason (at least to me ) someone ordered a CT SCAN of the belly and that showed a mass in colon.
She was in no shape to do any invasive procedures for diagnosing colon cancer , but more than that , diagnosing colon cancer would alter any treatments . Due to fear of bleeding from colon mass if she was started on blood thinner and with her low blood counts , we decided to do insert a filer in one of the blood vessel so that clot from legs would not travel to lung- embolism..
   When the radiologist went to insert the filter he realized that the entire blood vessel was filled with clot. So he could not do the procedure. But more of  a problem was that the clot occurred in the blood vessel as it was compressed by external tumor. So the narrowed blood vessel developed the clot and that was blocking the drainage  and so she had swelling of the legs . So then we had a catheter inserted in that blood vessel and clot busters were started . Now she will have to be on blood thinners too.
      So we have 80 years old patient  who has spread of a lung cancer , who also has anemia  and kidney failure and oxygen need for COPD , and has possible colon cancer and the a tumour that is pressing on one of the major veins that has clot. You get the picture. No matter how successful we are in treating the clot , her long and may be even short term prognosis is not very good . I did try to talk to her family as she has some dementia about this . But the cancer doctors and their nurse practitioners have not said a word about bad prognosis and so we are doing the bandage approach without being able to treat the underlying cause of the problem . The need to be honest but not blunt  and compassionate but still telling truth.

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