By Dr. David Kaminskas
Recently I saw a patient in my office for a routine heart checkup. He had bypass surgery many years ago and was still doing well. As he got up from his chair and climbed up on the exam table, I could hear wheezing. When I examined him, I thought I was hearing upper airway stridor. This particular man has mild dementia and was diagnosed with Alzheimer’s within the last few years. I suggested to the patient and his wife that we should investigate my physical findings with a chest X-ray. The radiologist who read the chest X-ray noticed the trachea was being displaced by a probable mass and suggested a CT scan to further investigate. The scan showed a massively enlarged thyroid gland pushing on the trachea and obstructing the main windpipe by 80 percent.
Trying to come up with the easiest and safest treatment, I initially thought that maybe we could use radioactive iodine and shrink the thyroid down, as we do with patients who are hyperthyroid with Graves’ disease. I referred him to an endocrinologist who told me that the thyroid was too massively enlarged to try this treatment; in a nice way suggesting maybe I should stick to being a cardiologist rather than trying to play endocrinologist!
So now we are talking surgery. The problem with major surgery in a patient with dementia is that it is not uncommon for the dementia to exacerbate post operatively. These elderly people can become scared, confused and even violent, finding themselves in the unfamiliar surroundings of the hospital setting. Sometimes, unfortunately, they never quite recover to their former mental state, and the surgical procedure ends up worsening their dementia permanently.
This had weighed heavily on the mind of his loving wife. She had been in touch with one of the well-known dementia associations, and their advice was not to pursue any surgery and just try to keep her husband comfortable and accept death.
One afternoon as I was seeing patients in my office, one of my nurses informed me that this patient’s wife had called insisting on speaking with me right away. She was beside herself trying to make this very important ethical decision. Catholic scholars use the terms proportionate and ordinary or disproportionate and extraordinary to help sort out a decision like this.
This man’s dementia was relatively mild and certainly not very advanced at this time. How fast it would progress was still unknown. His physical health, including his heart, was good. If we did nothing, I feared his death would likely be one of suffocation and be a miserable way for him to die, but not only that, awful for the family to witness. I believed in this case the benefits of surgery significantly outweighed the risks, and I also believed that surgery was a reasonable choice, and therefore proportionate and ordinary.
As I explained all this to his dedicated wife, there was a long pause in our conversation. I will never forget the question she asked me. “Are you giving me advice as a doctor or as a Catholic?” I replied, “I am speaking to you as a Catholic doctor.”
The surgery was not going to be easy. The sternum had to be opened just as with open-heart surgery, to get to the thyroid that had grown down into the chest. It took a team of doctors to complete the surgery. I was probably more nervous than they were. The very next day I went to check on my patient with great anticipation and peeked into his hospital room. He was sitting up in bed visiting with his lovely wife. He knew me at once as I walked in the room. I can’t describe how relieved I was. His mental status did not deteriorate post operatively as we had feared it could. The pathology showed thyroid tissue and no cancer present.
A statement from the United States Conference of Catholic Bishops which I quote often, helped guide me through this ethical dilemma. “The truth that life is a precious gift from God has profound implications for the question of stewardship over human life. We are not the owners of our lives and, hence do not have absolute power over life. We have a duty to preserve our life and use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome.” This surgery was beneficial, and considering the situation, I believed it was not excessively burdensome; but no question, the opposite could have been argued by some.
This man continues to live and glorify God. His family will certainly be challenged in the months and years ahead as his dementia progresses, and they will be asked to selflessly provide love and support. With God’s grace, this will be an opportunity for his wife and family to grow in their faith and spirituality.
Let us not forget: Life is a gift.
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