Susan Smith, a 59-year-old female is admitted through the ED with severe headaches, nausea/vomiting, vision problems, and other persistent symptoms. After conducting a neurological exam, the ED physician orders a contrast CT, which reveals Susan has a relatively large tumor that appears to be malignant. A neurosurgeon is consulted and he meets with Susan to inform her of the probable diagnosis, pointing out that the only way to be absolutely sure if the tumor is cancerous is to examine surgical specimens. He mentions that without surgery, she would likely die within six months. However, with surgery, and assuming malignancy, radiation and chemotherapy, there is about a 10 percent chance of surviving five or more years, depending on the precise makeup of the tumor. The neurosurgeon also notes that the operation carries a 5-10 percent chance of mortality or serious disability. After thinking about it for some time, Susan decides not to undergo surgery. In describing why, Susan talks sadly about her sister-in-law's long terminal illness, and about a friend's daughter who lived her life completely dependent on others — both situations she would rather avoid. Just to be sure that Susan is fully competent to make this decision, the neurosurgeon asks for a psych consult. The psychiatrist finds that Susan is fully rationale and very capable of making treatment decisions for herself.
Not happy with Susan's decision, the neurosurgeon appeals to her family to help change her mind. Though everyone in the family agrees, with the exception of Susan's sister, that Susan should pursue the surgery, Susan remains adamant. Within four weeks after being admitted, Susan returns to the ED unconscious and unresponsive. It is determined that her condition is due to the enlargement of the tumor. This time an MRI with gadolinium is performed to determine the exact status of the tumor. Shockingly, the radiologist reading this scan questions the original diagnosis: the tumor on the present scan lacks characteristics of the type of malignant tumor it had previously been thought to be. Its homogenous appearance leads him to suspect a meningioma — usually a benign tumor. If true, this would change the likelihood of survival. More than 60 percent of patients with meningioma survive at least ten years after surgery. However, Susan's only hope of survival still depends on surgical removal of the tumor, and the risks of surgery — including cognitive disability — remain the same given the placement of the tumor. The neurosurgeon again approaches the family and, despite Susan's verbal statements about surgery, tries to get them to provide their consent for it. Again all are in agreement, but Susan's sister who insists that the surgery not be done because that is not what her sister would have wanted and she made that very clear. The neurosurgeon protests saying that Susan made that decision with the wrong information and since she is no longer competent and without an advance directive, her previous decision does not stand. (Courtesy of Dr. Michael Panicola, SSM Health Care, St. Louis, Mo.).