The Doctor Will See You Now [Non-Fiction]

Chapter 113: Acute Medicine

An 85-year-old woman is admitted with palpitations. Her cardiac enzymes (heart markers) show a sudden, steep rise and we diagnose her with non-ST-elevation myocardial infarction (a type of heart attack). She is given medications and agrees to proceed towards a coro+/-PCI, short for coronary angiogram plus-or-minus primary coronary intervention (a catheter and contrast test of the heart arteries and, if needed, insertion of stent(s)). She can't afford the £6000 ish cost towards the stent (the procedure itself is free, but because of limited public funding, everyone must have a means of forking out for the stent cost if they wish to proceed towards coro+/-PCI.) She is reviewed by the cardiac team and they help her apply for charity funding and her application is approved.

The cardiac team also notes her most recent chest x-ray has a bulky shadow and advises that to be investigated before they proceed to coro+/-PCI. The worst case scenario was that the shadow turns out to be cancer. If the patient wishes for full work-up of the cancer, then she'll need a CT to see the location and details of the cancer and a bronchoscopy (a camera test of the lungs) to get tissue samples of the mass. But because once she has her coro+/-PCI, she will be on antiplatelet therapy (blood thinning medications) for a year, which means she can't get biopsies due to a high bleeding risk. Therefore, the lung shadow tests have to be done prior to coro+/-PCI.

The next step is to proceed to a CT of her chest to ascertain the nature of the shadow. Is it infection? Just some very prominent blood vessels? Or genuine cancer?

But because of the long waiting list for the CT, despite us requesting for her test to be done within 1 month, her appointment is given in over a year's time. If it were cancer, she'd very likely be dead by then.

We advise the patient and her family to consider going private for that CT scan, which would cost about £500. Then we can get her the inpatient bronchoscopy, get the tissue sample, and get the coro done. Everything could be completed within two weeks up to a month.

They refuse.

The patient doesn't want us to do anything about the lung shadow. "I'm old," she says, "I have to die of one thing or another."

She says that, but then also really wants her coro that could prevent her dying earlier. How bizarre.

The daughter is frankly offended that her mother has to wait at all for the CT but wants all investigations and procedures. When I discussed the situation with her at the bedside, she raises her voice and is unapologetically aggressive in front of the entire ward.

"My mother is old," she says to me. "Surely you don't expect her to wait for that CT. Surely she can skip the queue."

Nope. She has to wait in the same queue for possible cancer, just the same as every other patient who is queuing for a CT for possible cancer (the 'within one month' queue). She will not get special treatment just because the daughter yells at me in front of a bay of eight other patients and their families. If anything, an advanced age actually puts her at a disadvantage when it comes to getting aggressive treatment. She wouldn't be a priority compared to, say, a 60-year-old patient with a lung shadow. I ask her to consider going private for the scan again because of the long wait. She still refuses.

"We can get the coro first then get the CT in a year's time," the daughter tells me, as if it were obvious.

"She'll be dead by then if it were cancer. That defeats the point of her getting coro to prolong her life after a heart attack," I reply. Not to mention a massive misuse of charity funding, which could have gone to another patient who would actually live to next year. "Either you get that private CT and we do the full work-up whilst your mother stays as an inpatient or you accept she will probably die of lung cancer in a year's time and not get any lung cancer workup and not get the coro. If you want her to get the public-funded CT, it will be in several months' up to a year's time. If that's the case, then I'll discharge her for an outpatient coro to take place after that CT is done. She won't be staying in hospital for a whole year for the coro and she won't get that coro before the CT."

The daughter scowls at me. "If you let her leave this hospital for that private CT and something happens to her because of this heart attack, what happens then? Will you bear that responsibility?"

I tell her that all patients who have had heart attacks are at their highest risk of heart rhythm problems in the first week. If they don't wish for coro or they want to get the outpatient one and be able to go home in the meantime, they are actually fit for discharge after a week's medical therapy. And her mother has been here for a month already. So, yes. I can bear the responsibility.

The daughter tells me she'll think about it. Something tells me she won't.

The case was passed onto the next resident as I was away for a period of time after that. When I return, I find the patient discharged. It turns out the daughter refused to fork out for a private CT after all and demanded to proceed to the inpatient coro. The cardiac team refused to give the patient her coro because if the patient wasn't willing to get any workup for the lung cancer that would probably kill her within a year, then it would not be a prudent use of resources to give her that stent for her heart attack to prolong her life. Basically, if the daughter refuses to invest £500 to save her mother's life from lung cancer, the cardiac team will give that £6000 stent to prolong someone else's life. It was a waste of charity funding if the patient wasn't willing to use it to its full potential.