One of my patients, a colleague, had been readmitted in poor condition for recurrence of a primary lung sarcoma.
I spent a few minutes examining Dennis and chatting. He then, with a quizzical look, said, “Jim, I’m going to have to sue you. I know I’m dying. My wife Alice and the kids are still pretty young.” He saw my look of surprise and added, “You know, I don’t have much life insurance or other very significant funds for them to live on. It’s nothing personal. I know you’ve given me good care, but my wife is upset and tends to blame you for the outcome. I guess the hospital and others will be named.”
There wasn’t much more for me to say at the time except, “Dennis I can find another attending for you if you’d like.” He replied, “No, I want to stay with you.”
Dennis was a well liked family doctor. About five years earlier a “coin lesion” was discovered on a chest X-Ray. This 2cm spot in the right upper lobe had a smooth rounded border and didn’t contain calcium. A CT scan showed no enlarged lymph nodes and no other spots elsewhere. A needle biopsy of the spot was not diagnostic. We knew the spot was new because an X-Ray five years earlier was normal. He hadn’t traveled to an area where Valley Fever or other fungal infections were common.
At surgery, the right upper lobe was removed along with local lymph nodes. The lesion turned out to be a primary lung sarcoma, a quite unusual type of lung cancer. One of the lymph nodes was positive. We sent Dennis to local experts on sarcoma and several opinions from cancer specialists were obtained. The consensus at that time was that sarcomas don’t respond very well to either chemo or radiation therapy, but after further opinions, Dennis had a series of radiation treatments.
After that it was waiting. For three years, there was little change. Then fluid began to accumulate in the right lung cavity and some density in the area of radiation (often radiation changes). I drained the fluid from Dennis’ chest several times. No cancer cells were found. After more signs of progression but no proof of recurrence, I sent Dennis to the top academic chest surgeon in the area who admitted Dennis to the hospital. After more conferencing there, he attempted a complete removal of the right lung in order to try to remove all the residual tumor. Dennis had a very stormy post-op course and required ICU care and a ventilator for almost three months before being successfully weaned off. However, the sarcoma was never completely removed, thus still progressing.
He was then transferred back to my hospital where I met with Alice. Somehow I was the focus of her anger about her husbands tragic illness, and extensive suffering especially over the past year with heroic attempts to deal with the recurring sarcoma. We had social service and others involved. To say the least it was awkward to remain involved knowing that a legal threat was in the air.
Hospice met with Dennis and Alice. They mercifully stepped in and provided their healing palliative care. Although plans were made to have hospice at home, Alice balked. After a few weeks Dennis died peacefully in a hospital hospice unit.
As I think about Dennis and Alice, I wonder what I could have done better in communication. I’m not sure. I did find out that Alice tried to find a plaintiff’s attorney to file suit. They had several experts review the records, but they all advised her that she had no reasonable grounds to forge ahead legally with her complaints. I felt Dennis’ care had been good and wasn’t very concerned, but was reminded that it often takes several things to bring about a medical malpractice claim: a poor outcome, communication breakdown, anger, and a mistake or oversight of consequence. Our tort system is cumbersome and expensive. It’s not the major factor driving medical costs these days, but is significant and will need reform. But can we ever get there?
Jim deMaine is a retired pulmonary/critical care MD. He gives frequent talks to patients about end of life planning. You can follow him at End of Life – Thoughts from an MD, where this post first appeared.