“Doctor, What Would You Do?”

Herbert Beal took me by surprise yesterday morning with his question. He is a 70-year-old oxygen-dependent frail man with severe emphysema and a newly diagnosed 5.9 cm asymptomatic abdominal aortic aneurysm.

The vascular surgeons at our tertiary hospital couldn’t help him, so he was referred on to Massachusetts General Hospital in Boston. They felt his aneurysm could be stented, and his local pulmonologist thought he would tolerate that procedure, but probably not an open repair with a graft.

Thursday morning I got a call from Mass. General. They wanted him to have a cardiac evaluation before the operation next week. The chief of our local cardiology group agreed to see him at 11 am Friday.

Late Thursday afternoon Mr. Beal called because he had a cold and was raising colored sputum. I agreed to see him as a “double book” Friday morning on his way to the cardiologist in town.

In the exam room was Herbert Beal and his wife, who had never come with him to an appointment before. He had rales and rhonchi in both lungs, and deserved an antibiotic, especially with surgery next week. I also offered him a flu shot and made sure they knew how to get to the cardiology clinic.

As I was about to leave the room, Mr. Beal cleared his throat and asked:

“Doctor, what would you do?

I looked at him again, and he continued: “Would you have the surgery?”

His wife spoke softly: “Herbert and I have talked about this – I understand that death from emphysema can be very uncomfortable, and death from an aneurysm is usually quick…”

I thought for a moment before answering:

“This is a high risk situation. As long as the aneurysm can be stented, your lung doctor thinks you’ll be OK with the surgery, and you’ll soon hear what the cardiologist thinks. If stenting doesn’t work, an open repair would be very risky.”

I paused and thought again.

“We don’t know how long you’ve had this aneurysm, and we don’t know how fast it will grow. If I were in your situation, I’m not sure I’d have the procedure.”

They thanked me and went on to his cardiology appointment.

Just as I was about to leave the clinic last night I got the cardiology report – OK for the stenting, very high risk for an open repair, just as expected. I called the Nurse Practitioner I had talked to before at Mass. General.

“Oh, really”, she said. “I heard from his pulmonologist yesterday, and he told me Mr. Beal had decided against the surgery. I guess we’re still on then – I’ll email the surgeon.”

What a terrible choice to be faced with…

1 Response to ““Doctor, What Would You Do?””

  1. 1 Mayhem October 20, 2008 at 4:13 am

    In a way, I agree with their logic. If the end result is the same then quick and painless is better. But I don’t know that I could have brought myself to answer that question. I also don’t know if that will make me a bad doctor.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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