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When Age Plays A Role In Medical Decision-Making

Missed Diagnosis Lawsuit and the Dynamics of Age Related to Risk

Years ago I had the opportunity to care for Mr Smith, a 101 year old man who presented to the hospital with chest pain and shortness of breath. Besides having  101 year old heart and lungs that tend to follow their own  biological clock,  this man also had a massive chest tumor filling 85% of one side of his thorax.

Whoah really?  What does that mean in a 101 year old man?  Most folks this age have exceeded the normal bell curve distribution of life and disease.  When you reach 101 years old, there isn’t a lot of chronic anything you can catch with the expected time you have left on earth.

Every now and then, however, we find patients who are the exception to the rule, such as the 101 year old guy that present with a new cancer diagnosis.  That’s where being an internist comes in handy. What is an internist?  An internist is a physician for adults who takes the time to put all the pieces together and makes a relevant plan.  What is a hospitalist?  They are often internal medicine physicians who restrict their care to hospitalized patients.  They keep the big picture in mind while paying close attention to the details.

How do you work up a 101 year old with a massive chest tumor?  If you are formulating a hospital care plan like you do hospital patient safety, with robotic Joint Commission standards, then you activate the robot hospitalist and consult the pulmonologist for the shortness of breath, the oncologist for the lung mass and the cardiologist for the chest pain. Or you can activate the internist and formulate a reasonable plan based on the patient and their condition, not  their disease.  How does one mold a  robot hospitalist into an  internist hospitalist?  I don’t have an answer to that question.

With that in mind, I did a little research on this man’s chest process and discovered he had a radiograph  2 1/2 years prior showing a large chest mass consuming about 50% of his thorax.  Lets just say I was shocked  to say the least.  After digging into the details a bit more, I realized that the ordering service  had failed to implement a plan of action regarding the chest mass.   What we had almost three years ago was a 99 year old man with a large chest mass consuming half of his chest and no action was taken to acknowledge the findings or discuss the findings with the patient and their family.  This was the classic case of a missed diagnosis lawsuit waiting to happen.

This is not the same as a missed diagnosis lawsuit filed by a family against an ER doctor for missing a pulmonary embolism in their 22 year old daughter who presented with chest pain, a normal d-dimer, a normal EKG and a low probability V/Q scan.  Medicine is not 100%.  But bad outcomes happen despite our greatest efforts.

That’s not the case of the 101 year old man with a progressive defined chest mass that was left unattended for almost three years.  What do I do now?  What should I do know?  What would you do?

I remember thinking to myself at the time that the only reason this gentleman was still alive today,  after almost three years of having a progressive massive chest mass, was because we didn’t do anything.   Had we intervened, knowing what I know about the rest of his story,  he would have been dead several years ago after undergoing his last few months being poked and prodded, literally, to death.  Doing nothing often provides patients with a greater quality of life than doing something.  And that’s the value a hospitalist/palliative care collaboration can provide for patients in a common sense approach to quality care.

I have argued previously and the studies are compelling  that living a healthy lifestyle will help you  dramatically reduce the risk of debilitating diabetes, heart disease, cancer and stroke.  I have even argued we should stop insuring against disease, which is nothing more than  an  unsustainable payment model for health care for bad life choices, and instead insure against lifestyle choices using  Lifestyle Protection Plans (LiPPs) as a model of insurance.  At least we are insuring action, not reaction.

Some folks like to argue that total government expenditures for folks who practice healthy lifestyles are more than those who die early because of preventable disease.  That’s a function of bad government finance, not a problem with healthy lifestyles.  We need a government that can say no. That government doesn’t exist.

If you take age velocity into the equation of health care  and life consumers vs producers,  you’ll understand why living healthy lifestyles and then dying a comfortable death without heroics is the cheapest and most compassionate way to go.  Live long and finish strong.

Many doctors in my position may have let this record research information slide and leave it alone.  Had I not looked at old records, I would have never known.  But the right thing to do was to be honest and tell the family someone missed the diagnosis.  And I did.  I told the family that we failed to inform them of a probable cancer diagnosis almost three years prior.

With that information, I also explained that doing nothing was likely the best course of action and was probably the only reason dad was alive today.  I apologized on behalf of our profession.

The family was obviously stunned, but they understood the condition dad was in.  In the end, they appreciated the honesty, but made sure I knew that if dad was 30 years younger, they would have sued for a missed diagnosis lawsuit.

Many folks like to say age plays no part in medical decision making.  It does.  It also, apparently,  has a roll in deciding whether families file a missed diagnosis lawsuit or not as well.

*This blog post was originally published at The Happy Hospitalist*

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