When I was on pulmonary consults in my first year of fellowship, I had a consult for a patient with a chronic pleural effusion. This was a common consult, the question being would you be able to do a thoracentesis, a procedure that uses a needle and catheter to drain the fluid that surrounds the lung.
Reasons for this can be for diagnosis, but it is also done for therapy because often it is causing some compression of the lung, making it hard for the patient to breath. Sometimes, though a patient may be asymptomatic. They go about their daily activities, and they are breathing just fine, without shortness of breath, discomfort or need for any supplemental oxygen.
This was the case with this consult. He was a 92-year-old man, who had recently gone through surgery for colon cancer and it was complicated by a blood clot in his upper arm. When he started having some pain in that arm again, he came to the emergency department where he was diagnosed with a skin infection and incidentally had some imaging done that showed a large right pleural effusion, or fluid around his lung.
When looking at all the imaging that he had been done, in the past and the current one for comparison, it was a fluid that had been there for several years. Chronic. And when I examined him, he was breathing on room air, with good saturations, and not in any respiratory distress. So, when I spoke to him about the procedure, the risks and benefits, of course I was thinking through my own thoughts. Thinking about how as I got older or may be from what I had seen and experienced in fellowship so far, my thoughts about procedures, interventions, and invasive procedures has been evolving. Still is.
I had in my own mind thought that if I was this gentleman, with my age, my current state, where I was breathing fine, and knowing that this fluid had been there for years, and not much had changed, I would have opted for no thanks.
In light of what the most likely reasons for having fluid around the lung (the man had a long cardiac and renal history making this pleural fluid likely related to those two things, meaning that it would also likely return to that space because the heart and kidneys being sick in general), I would have said, let bygones be bygones, and leave me be.
Don’t get me wrong, a thoracentesis is a very safe, sterile procedure, done at bedside, with ultrasound, and quick and easy. It is not like open heart surgery. But still, it has its risks like anything that involves a needle. I explained to him and his wife the procedure, all the risks and benefits. I waited.
What would you do? He asked me. And that’s when I stopped myself from truly saying my opinion. I didn’t want to influence him. My job was to guide, provide options, but I felt strongly that patient autonomy needed to be held to the highest degree in this situation. Maybe because he was older, and maybe it was because he was complicated by recent malignancy, blood clot, heart conditions, and kidney problems, that I really wanted him to make this decision. Did he want to add one more risk to his already lengthy medical repertoire.
I told him, "I want to do what you want to do." And waited. Hoping my expression or wording was not influencing his decision.
He looked at me, then said, “let’s drain the fluid.”
I was a little surprised at his response, but then I stopped myself again from trying to express any emotion besides support for my patient’s decision. We made plans to hold is anticoagulant medication and do the procedure the next day.
The next morning we went through this process again-- I explained the procedure and the risks and benefits. He seemed a little more nervous this time. We had all the equipment in the room, and it must have really sunk in that this is what was happening. I offered him the decision. I felt like I was going to get another answer this time. But I was surprised yet again. He looked at me on cue, the decision in his court. And he said, “let’s drain the fluid.” Not the answer I expected, but maybe it was because I was still in my own world, thinking about how I would have said no.
I began the process of scanning him with the ultrasound machine, and in this, was trying to make him more comfortable with some small talk. Somehow, I got around to asking him what he was looking forward to, and he said, “I’d like to make it to another Christmas.” And I felt the pang in my heart. The man was 92 years old. And in that, while I was thinking about what I would do in his shoes, I didn’t really think beyond the procedure to the moment, the week, the other things.
I am sure when you are that age, you think about the next moments carefully, how many times will I get to do this? Will I get another? Another Christmas, another day, another? I quickly tried to cover up my feelings, with a perky, “well it’s almost here, you will.”
It was Christmas week, thank God, and it was almost here. He was quiet, but I wasn’t sure what else I could say, so I began to walk him through what I was doing instead. And tried not to think about anything but doing the best job on this procedure. Because I was going to play my part as the pulmonary consult team. He was going to get another Christmas.
