Clinical Geriatrics

Case Presentation
Mrs. S is an 83-year-old widowed woman who presented to her primary care physician with complaints of difficulty swallowing. She was found to have an enlarged thyroid gland. The patient was referred to an otolaryngologist who performed a fine needle aspiration of the mass. Mrs. S was diagnosed with poorly differentiated thyroid carcinoma and underwent a thyroidectomy. At the time of surgery, the cancer was found to be invading both her trachea and esophagus. After excision of the tumor, Mrs. S recovered enough to swallow most foods and breathe freely. Unfortunately, the tumor could not be totally removed. She was referred to a regional cancer center for follow-up treatment.

The oncology team at the cancer center found that Mrs. S suffered from a high-grade malignancy. She was advised that a course of radiation therapy may slow the growth of the tumor, but carried the risk of esophagitis, tracheitis, and the possibility of requiring a feeding tube, tracheostomy, or both during the treatment. She was also advised that given the location of the tumor and nature of the malignancy, hospice care was also an option. Mrs. S had no children and her only available family members were a niece and nephew. Mrs. S asked if her relatives could be included in the discussion of her care, as she was uncertain of what decision to make. Mrs. S had written a living will 10 years ago following the death of her husband from lung cancer. She wrote that after seeing her husband waste away for three years and die while on a ventilator, she would never want to be resuscitated. However, she was having a difficult time dealing with her diagnosis and was uncomfortable with the idea of hospice care. She told the team that she did not feel sick, but does not want to face the end of her life with tubes in her throat or hooked up to machines. The staff hoped that the family meeting would be helpful.

The family meeting with Mrs. S, her niece, and nephew was difficult. Her niece and nephew felt strongly that Mrs. S was unable to make any decisions about her treatment. They described a history of depression that Mrs. S suffered from for many years, with one psychiatric hospitalization five years ago. Mrs. S became defensive and angry during the meeting, stating that her niece and nephew were only interested in getting an inheritance from her. She left the meeting still ambivalent about her treatment options. Her niece told the team that Mrs. S should get radiation therapy or she would take her aunt somewhere else for treatment.

The team was divided about how to proceed. They decided to ask Mrs. S to meet with the psychiatrist and also reviewed her advance directives. Mrs. S had completed “Do-Not-Resuscitate” (DNR) documents prior to her surgery and again when she came to the cancer center for evaluation. Some team members were concerned that her history of depression and difficulty reaching a decision about treatment limited her capacity to complete such definitive documents. Other staff noted that Mrs. S did not have any symptoms of active depression and displayed a clear understanding of her treatment options. They expressed concern that her niece and nephew appeared to be coercing the patient to accept treatment that she did not want. Given her advanced cancer and poor prognosis, Mrs. S was working through the process of how to manage end-of-life issues. Several team members felt that there was no reason to question her capabilities and wanted to allow her more time to reach a decision.

Mrs. S agreed to meet with the psychiatrist and also told the team that her niece arranged for her to see another oncologist for a second opinion.