Sunday, August 23, 2020


    All of us know that when there is birth,there is death.Anyone who is born, will die. But inspite of knowing this we all are not only prepared for it nor we want to accept it. I was listening to Swami Sarvapriyanand, he is in charge of hermitage in NY,when he narrated a story where this man complains to Lord of Death , that he never was given warning about death approaching. The Lord of Death answered that what do you think was the meaning of thinning hair line  and gray hair  and loss of teeth and wrinkles and sagging skin  and many other things that we notice  and ignore. I find the same thing in my medical practice. And I am not blaming anyone , but I feel that WE are never ready or accept it. My father dies at age of 88 years of age 11 years ago  and he was never sick before his last sickness, i was not prepared for it  and sometimes even today I think of him  and miss him. So I know this is common to all of us . That brings me to the story for today. 

     I have known this patient for many years . He was 78 years old male and he was morbidly obese and had COPD  and also sleep apnea.He came to me  and the work up showed that he had COPD  and OSA, and he had heart problem and high blood pressure. He also had congestive heart failure . I treated him and he was fine . He was very limited in his activity and he basically stayed home  and was taken care by his wife. He would walk in house to eat and take shower  and go to bathroom but no other physical activity and over period of years that I followed he got slowly worse. He was on oxygen  and then the need for oxygen increased  and then he needed 4-5 L oxygen all the time  and in spite of using oxygen, he was short of breath. I do chest X- ray every year and when I did X- ray  I saw a density that was not there in past X- ray. So I did CT SCAN of the chest  and that showed a mass . This was highly suspicious for lung cancer. I ordered PET scan  and that showed high uptake in the mass . His overall status was such that we could not do any invasive test and my feeling was if we get the biopsy positive for cancer we will treat it as cancer and if I am unable to get adequate tissue to get diagnosis of cancer I will still like to treat him for cancer . So I sent him to radiation doctor  and they agreed and gave him radiation under the diagnosis of cancer based on all the tests. 

     He did OK  and continued to live his usual life style. He had gained some more weight and also had swelling of feet.But otherwise he was fine. We did new CT SCAN and the cancer was improved  and there was small amount of scar tissue where there was cancer. Then I got a call that he was in ICU. He had confusion and altered mental status  and so family took him to ER  and he was admitted to ICU as he had elevated carbon di oxide. (The function of the lung is to take in oxygen and wash out or get rid of CO21 In lung disease early stages the oxygen and CO2 are normal , then oxygen drops  and patient need oxygen but CO2 is normal  and in advanced stages CO2 also goes up)The CO2 was so high that he had to be put on noninvasive respirator. He continued to be non responsive to verbal stimuli. The usual treatment was carried out and he did improve somewhat. I spoke to his family some of whom were in medical field , and tried to make him DNR as to me his prognosis was very poor with all the medical conditions  and also obesity and cancer of the lung and heart and lung problem and he would not have very productive life. . 

   It was difficult for his wife to accept it even though she lived with him and he had not done much physically in last 2 years . He finally was made DNR  and then I called Hospice . We still continue to have discussions  and then after 3 more days they agreed for Hospice - comfort care . 


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