DR - II

He was the last patient of the day, with the (simple enough) complaints of nasal stuffiness and discharge, facial pressure and cough. I had gotten used to the organized chaos of the clinic – the myriad patients pointing to their throats, measuring out GERD or allergic rhinitis medications into small envelopes, writing makeshift prescriptions on post-it notes in limited Spanish – and was expecting a nice textbook case of chronic sinusitis with which to round out the day.

I was halfway into that particular question algorithm when the patient’s daughter quietly interrupted. She handed me a piece of paper with a biopsy report dated seven days prior stating that her father had a sinonasal undifferentiated carcinoma, a malignancy with an extremely poor prognosis even with optimal surgical and adjuvant treatment. I looked at the report and then glanced at the patient, who continued to talk happily without a care in the world. I asked him (through the translator) what he knew about his condition, and he stated that he knew he had a biopsy, but nothing more.

This was a relatively alien situation to me, as aside from PCM sessions with standardized patients, I’ve never had to tell anyone that they had a malignancy with an extremely poor prognosis. I decided to let the attending deliver the news and conducted a thorough physical. Once I left the room, I took the translator and the patient’s daughter with me to present the patient. We explained the seriousness of her father's condition and the necessary therapeutic options. The patient’s daughter was insistent that her father not be told about his diagnosis. As visitors to the country, we agreed, but wrote her a letter of referral to the country’s only cancer center should she change her mind. After several awkward moments dictating said letter to an exceedingly patient Peace Corps volunteer, she thanked us before we went to examine her father further.

My time at Loyola taught me, among other things, the importance of patient autonomy and its place as a cornerstone of American medical ethics. We did not impose this particular value in this case, and did not feel as if we'd committed a grave ethical misstep. Indeed, the same scenario might have played out exactly as described in my family. It would take more than a blog entry to fully discuss the differential value of patient autonomy in Santiago versus Chicago. Cultural sensitivity notwithstanding, I still felt a pang of guilt when, upon leaving, the patient asked if his nasal stuffiness and facial pressure would ever improve. I told him that the medications we provided would take care of his symptoms, all the while glancing at his daughter to see if she'd change her mind. She didn't. They left and I wished them well.

Ryan JE Salvador, MSIV
Santiago, DR