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April 24, 2005 Internship Journal

I am doing my second month of neurology. My previous month was in November and I really enjoyed it. Neurology is the most applicable rotation to my career. One patient from the month will forever be in my thoughts.

Mrs. Williams is a 40-year-old who presented to the hospital on March 31 with continuous seizure activity in her right hand. She has a history of seizures relating back 13 years. A CT scan is part of the work up for new onset seizures, or an increase in seizure activity. This showed what looked like a stroke. By this time, her seizure activity was under control, so we began to order tests that might explain why a 40-year-old without medical problems like high blood pressure or diabetes had a stroke. We also ordered a MRI.

Her MRI of her brain showed a large left-sided tumor where what had looked like a stroke was. On rounds, we gave her and her family the bad news. They were not emotional at all. It was hard to tell if this was because they did not understand the gravity of her diagnosis, or they were just in shock.

I was off the following day and when I returned I found Mrs. Williams sleepy and minimally responsive. I was told that she was like this the previous day. As part of a mental status change work up, several tests had been ordered. She was found to have a high ammonia level and decreased thyroid function. Her family came to visit her, and asked me why she was not responsive anymore. I told them about these results, and explained to them that after we corrected these problems, she should wake back up.

The next morning she remained minimally responsive. Her ammonia level was better, but it was still not normal. My theory had been that her liver was not getting rid of it because of all of the seizure medicines that we had given her. They can also cause someone to be sleepy, so I held them.

This unfortunately, did not make a difference. Her ammonia level corrected over the next two days. Her blood levels of her seizure medicines trended down to low normal levels. I continued to replace her thyroid hormone and even diagnosed her with adrenal insufficiency (adrenal glands make cortisol, a hormone that is needed during times of stress) and began treating her for this, but she still remained minimally responsive.

Around this time, she also underwent a brain biopsy to see what kind of tumor she has. She was diagnosed with anaplastic astrocytoma (a high grade, malignant, aggressive primary brain tumor). This meant nothing to me at the time, and I was open and honest with the family about my lack of knowledge when I told them the diagnosis. I suggested that we have a meeting with my attending (a neurologist) as well as the cancer doctors, so we could discuss treatment options.

The family meeting was standing room only. She has a wonderful, supportive family, so there were 11 family members there. My attending explained that this tumor was not curable, but we could treat it and extend her life. Without treatment, she would probably live about 3 to 9 months. With treatment, she would probably live 15 to 18 months. The big unknown is how she would be during this time. Her mental status had still not improved over the last week and a half. As a medical team, we felt like the radiation treatment would help her mental status and make her more functional. We tried to explain this without too much bias towards treatment.

As you all know, I am a fighter. I would certainly want the radiation if it meant giving me the possibility of a few more good months. To me, the decision was an obvious one. However, this was obviously not my decision, or the other doctors, to make.

We also discussed code status (in the event that her heart stopped beating or she stopped breathing) and the possibility of a permanent feeding tube. This was obviously a lot of information at one time, so we gave them some time to think about it at the end of the meeting.

After approximately 45 minutes, I returned to see if they had come up with anything. I also emphasized that we were not rushing them. I could sense that they had not yet come to a conclusion, so I suggested that they go home and continue to discuss it. I did however suggest that they decide something about her code status. They had said that they did not want to see her suffer, so I suggested that she should be a DNR, and fortunately, they agreed.

The following morning I came to see Mrs. Williams and she opened her eyes when I called her name. She was able to follow commands and carry on a conversation. I asked her if she remembered having the conversation when we told her that she had a brain tumor. She said yes. Then I told her we were considering treating with radiation. I explained to her that it would not cure her, but it would extend her life and hopefully make her more functional. I asked her if she was interested in this, and she said she was. I contacted the radiation oncologist and gave him the good news, and we talked about hopefully starting treatment the following day.

That night, I called her sister to tell her the good news. When I talked to her about moving forward with treatment, she told me that they did not want her to have the radiation because they did not want to see her suffer anymore. I told her about the conversation I had with Mrs. Williams that day. She stated that she was not awake enough to make that decision and she did not think she fully understood what the treatment would entail. I told her that I thought she was certainly awake enough. Her response was, "Well, that is our decision."

I hung up the phone shaking my head. I certainly did not want to see her suffer anymore. However, I wanted the limited time she has left to be as functional as possible. In talking to the oncologist's, radiation treatment would offer her the best hope for this. I was once again stuck with the frustrations that this was not my decision to make.

The following morning I was greeted with an even more alert and awake Mrs. Williams. I told her that her sister did not think she was awake enough to make decisions. Without trying to overstep my bounds, I asked her if she would like to speak to the radiation oncologist, so she would fully understand what the radiation treatment would entail. I figured I would offer her that and then if she decided she did not want to go further, I would just have to understand. She said she would like to speak to him.

Later that day, she told the radiation oncologist she would like to pursue treatment. I was very excited, but once again tried to stay unbiased. I went by her room with my attending, and we asked her again if she wanted to have the treatment. She once again stated that she did. I was confident that she was competent to make this decision and that she made it independently. I asked her if she wanted to call her sister and tell her or if she wanted me to. She stated that she wanted me to.

That night, I called her sister. At first she was upset and said that it sounded like we wanted to treat her more then she wanted us to treat her. I told her that was not true, and that she should talk to her sister about it.

The following morning, Mrs. Williams had already spoken to her sister, and we all were on the same page. We talked about getting her to rehab so she could work with the therapists while getting her treatment. She liked this idea.

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