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A Physician in an

Overseas Hospital

Part I

A physician, aged sixty-eight, was admitted to an overseas hospital after a barium meal had shown a large carcinoma of the stomach.

He had retired from practice five years earlier, after severe myocardial infarction had left his exercise tolerance considerably reduced.

The early symptoms of the carcinoma were mistakenly thought to be due to myocardial ischemia. By the time the possibility of carcinomas was first considered, the disease was already far advanced. Laparotomy showed extensive metastatic involvement of the abdominal lymph nodes and liver.

Palliative gastrectomy was performed with the object of preventing perforation of the primary tumor into the peritoneal cavity, which appeared to the surgeon to be imminent. Histological examination showed the growth to be an anapestic primary adenocarcinoma.  There was clinical and radiological evidence of secondary deposits in the lower thoracic and lumbar vertebrae.

The patient was told of the findings and fully understood their import. He was not asked for, nor did he offer, any expressions of his wishes with regard to resuscitation or aggressive life support measures. His primary physician had indicated nothing about such decisions in the medical record.

In spite of increasingly large doses of pethidine, and of morphine at night, the patient suffered constantly with severe abdominal pain and pain resulting from compression of spinal nerves by tumor deposits.

On the tenth day after the gastrectomy, the patient collapsed with classic manifestations of massive pulmonary embolism and suffered cardiac arrest.

A staff physician happened to be on the unit when the arrest occurred. His first impulse was to order full resuscitation measures and to undertake an emergency pulmonary embolectomy.

But he hesitated a moment, wondering whether this was the right thing to do with this particular patient.