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The Patient's Story

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Mr N was a 55-year-old man with a radiographic diagnosis of pancreatic cancer invasive to colon and liver; however, the results of a biopsy were nondiagnostic. Mr N met with his primary care physician, Dr W, and told him that he wanted to pursue a tissue diagnosis and consider anticancer treatment, yet he valued his physical functioning even at the expense of longevity. He wished to avoid being "hooked up to machines" for a prolonged period but would not commit to a do-not-resuscitate (DNR) order until a diagnosis of cancer was confirmed. Mr N told his physician that he preferred to pursue this workup at another hospital because he felt his diagnosis had been missed initially at his primary care physician's facility. Mr N made all of his decisions with the assistance of his daughter, Ms N.

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While awaiting further diagnostic testing, Dr W referred the patient to his hospital's palliative care clinic. Mr N expressed to the palliative care team that, above all else, he wished to remain comfortable and functional. He also stated that he was forcing himself to eat and required laxatives to initiate bowel movements. One week later, the patient returned to his primary care physician complaining of fatigue, anorexia, bloating, and worsening constipation. Concerned that he might be experiencing bowel obstruction, Dr W advised surgical consultation, and the patient said he would pursue that at his local hospital. Yet, this did not happen, and several days later he presented to Dr W's hospital with increasing abdominal distension and pain and was admitted to the medical service. Abdominal radiographs showed no obstruction, and he was discharged after treatment with enemas, morphine, and steroids.

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Four days later, Mr N was readmitted with similar symptoms. Again without radiographic evidence of obstruction, he was treated conservatively. On the third hospital day, after no improvement, surgical consultants recommended an abdominal computed tomographic (CT) scan. When asked by his physician what he would want done if his condition should deteriorate suddenly, Mr N said that he wished to be kept comfortable but would not rule out the possibility of surgery. He remained reluctant to agree to a DNR order. Two days later, while still awaiting the CT scan, Mr N acutely developed severe abdominal pain and a radiograph revealed free air under the diaphragm. With consent from the patient's daughter, he was taken emergently to surgery. The surgeon, Dr V, discovered a perforated cecum and diffuse intra-abdominal carcinomatosis. A diverting procedure was performed, his abdomen was left open, and he was discharged to the intensive care unit (ICU), intubated and hypotensive.

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Dr W spoke with the patient's daughter and ex-wife, who were distraught at what they saw in the ICU and who felt that the patient would not have wanted to be kept alive in this situation. They said that 10 days earlier he had completed an advance directive ...

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