Sunday, October 18, 2020


      In medicine we often have health and sickness and also life and death situations or need for making such decision. This is not surprise at all. But sometimes for a physicians to bring up the topic of DEATH is not well received  and some time patients or the members of the family are not happy that I bring it up. 

   I had seen this patient for last couple of years and she was 75 years old female who had chronic cough  and so she had work up done and she was told to have got Fibrosis or so called IDIOPATHIC PULMONARY FIBROSIS. The disease is uniformly fatal. But in my experience that happens in 20-30 % of the patients  and some get worse rapidly and others slowly  and some never get bad enough. This is not what the medical literature will state. Again this is based on diagnosis by CT scan . Anyway she had fibrosis  and also it was or it had gotten worse. She was short of breath and had chronic cough and I did the work up and she needed oxygen  and she would drop her oxygen level even walking few feet and she needed oxygen 24 hrs a day . She had CT scan - High Resolution CT scan  and she had the typical findings of fibrosis  and so we did routine work up and then started her on a  relatively new medicine called OFEV . This I think was approved by FDA in 2014 or 2015 . She was doing OK and she continued to have problems Due to progressive nature of the disease, I discussed with her and the family on  lung transplant  and she wanted to go to a university center as some of her family was there. The appointment was postponed as the center was in another state. She continued to have very limited activity and was some what stable. She had some cough and she seems to be stable with Ofev . She had appointment with the transplant center after 6 months  and she decided that she did not want to have transplant as she felt 'she was too old '.She then had respiratory infection and she was more short of breath and so she was admitted . She had new CT scan and that again showed fibrosis, but also showed a new density at the edge of the lung . I was not too sure as what that was as it did not look like typical cancer. I asked her to get me old CT scan cd. I looked at it and in old CT scan that area did not show the density. So when she came to my office , she came with her son. I explained them the new findings  and told them that I am concerned about developing cancer . I also told them that if it is cancer she was not a candidate for invasive work up given her poor lung condition . The bronchoscopy would not get to the area as it was at edge of the lung . The needle biopsy - by putting in the needle from chest wall in to the lung was possible but there was very high risk of collapse of the lung as puncturing lung was a possibility . Certainly 'cutting it out ' by surgeon was out of question. So I ordered a PET scan and told them on what could be done as treatment if at alll we can do some without biopsy . 

    At the end of lengthy discussion I also told them that she needs to have living will and decision as to what she would like if she could not breath or her heart stops --the so called DNR status. OI told her that if she would go on ventilator, with her given lung capacity, it will be impossible to wean her off the ventilator. So then the family will have to make decision on so called "pulling the plug". So it will be better if she has discussion with them and make decision in advance. I also suggested that she should consider not going on respirator or make  herself DNR  by signing forms. She seemed to be receptive . But the son told her that he does not think she should be DNR  and we should do everything possible . I told her that that is why she should have discussion with family members. So that will avoid the conflict when the time comes.


Friday, October 9, 2020


    In life most of the time we have situations where average person or for that matter even kids know what is right and what is wrong. Even when child is caught with his hand in cookie jar , he tells mom that he was getting the cookies for mom. So we all know most of the time and there are some situations where the situation is not clear  and one could go either way and both things may be right. We in medicine have certain situations where we could go either way and will be considered right. Just to give an example, one at certain time in our life can decide not to go on respirator  and some may want to do it even with the odds against the survival and we can not fault the decision . I came across such a situation recently . 

     I was asked to see a patient in office for abnormal CT scan . I was told my office that there was a patient who had lung mass per primary physician and they wanted me to see him soon. So I saw the patient soon He was 89 years old male who had not smoked for 40 years. He had dementia  and so the family wanted to put him in day care for day time  and the center needed  chest X- ray  and it was abnormal. So the primary care did CT scan and that showed a mass and so he was sent to me . 

  When I talked to the family - the wife and daughter , the patient did not answer any questions  and he could not tell me the day or the month and also the name of the US president . He had bladder cancer many years ago and he had no pulmonary complaints He looked very comfortable  and had no idea as to what  was going on and why he was in my office. I reviewed the CT scan and talked to the family. He had what looked like cancer . As his bladder cancer was many years ago I felt that this was likely to be due to cancer of lung . So I told them that we normally like to answer 3 questions  Is it cancer , Has it spread  and What is the treatment choice. So I asked them as to what would be the choice of treatment . I told that  I don't think he would be a candidate for surgery due to dementia and age even though the stage of the cancer was resectable. The chemo would be very bad  and should not be considered. So the only treatment  that could be considered would be radiation . I   i also told them that DOING NOTHING would be also an option  and that may not be bad idea as with his dementia, not much could be changed and he was 89 years old . So the good patient and physician could do PET SCAN and offer radiation and good physician and patient or family could consider no treatment and no work up. Either way is right  and wrong