Ashes to ashes

Mrs G, whom I mentioned in passing the my last posting, was a 77 year old lady, who upto two weeks prior to her admission had been independent - even getting out by bus to do her shopping and managing her own cooking and cleaning.
She had been in hospital three weeks before, with back pain. This had been a long standing problem, but it had worsened. X-rays of her spine were normal, myeloma was ruled out and her pain relief was optimised, so she was sent home.
However, since her discharge, her back pain flared up again, and slowly she found it difficult to manage. She was sleepy and occaisionally became muddled. Her son and wife who live an hour away became concerned and took turns staying with her. But soon, they could not cope either - she was sleeping most of the time and when she was awake, she was in tears because of the pain.
So back into hospital she came, and into a side room on my ward. The consultant on call was concerned by her back pain, and the fact that her back was very tender to touch, so he arranged a MRI of her spine. It found a small high intensity lesion of questionable significance and widespread degeneration of her spine. Just in case the lesion was due to an infection, she
was started on iv antibiotics that night. In the morning, her case was discussed with the infectious diseases consultant who felt that it was probably not an infection, but that the neurologist needed to get involved - he was very concerned about her drowsiness and confusion. I did a full neurological examination - which was normal, and a mental state examination, where she achieved a score compatible with dementia. I was concerned. I had a chat with her daughter-in-law and became more concerned: three weeks ago she was helping her grandchildren with their homework, but now she did not know what season we were in. My SHO and registrar decided a CT scan of her brain and a bone scan* may give us a clue. In the meantime, I spoke to the neurologist. After I had finished describing her case, the first thing he asked me was "Don't you think she's dying?". The question really threw me. Thus far, my only experiences with death had been with patients who had a number of things wrong with them - but here was a lady who had something going on, but I did not know what, and the idea that she was dying seemed preposterous. After stammering that I really did not know, I went on to tell him what our plans to investigate were. He agreed to look at the MRI films and suggested that she have contrast for the CT**. However, that evening when her blood tests came back, her kidney function had deteriorated, so to prevent the contrast doing any harm, I wrote her up to have intravenous fluids overnight and a couple of doses of acetylcystiene**. The next morning, I found that she had only started iv fluids a couple of hours before and that she had never received the acetylcystiene - there was no way she could be given contrast, so she had the CT without it. The CT came back normal. It was back to square one.
She had a raised calcium, which fitted in with the degenerative process affecting her spine, so we carried on giving her intravenous fluids and monitoring her urine output. But she was getting more drowsy, and being in a side room meant that it is difficult for the nurses to keep an eye on her, so the minute a bed in one of the bays became vacant, I had her moved.
Then she started breathing very fast, but despite this her blood oxygenation level was lower than expected, and her heart rate increased to try and compensate for this. Just in case she had a blood clot in the lung, we started her on a drug to thin her blood and arranged for a V/Q scan**** as soon as possible. We also had a chest x-ray done, which suggested consoliation of part of her lung. The infectious diseases consultant suggested starting her on antibiotics, just in case it was an infection, but it still could not account for her being so drowsy.
The next day, the cancer markers, that my SHO had suggested testing for three days previously, came back sky high. She needed an urgent CT of her abdomen. But we could not convince the on call radiologist that it would change immediate management, because she was still drowsy and confused and constantly out of breath, not to mention the fact that she had barely been eating since her admission. However, he did promise to do it the following day.
It was too late. I went to handover, to find out that she had died at 0245. Her son missed being there by 15mins. I went to the ward - to find my SHO there- he too had just found out and was looking upset. We still had no clue what she died of - she would need a post-mortem (PM).
All the while Mrs G had been in hospital, either my SHO or I had been in touch with her son and daughter-in-law, updating them and I had only just spoken to them the day before, to let them know of the results of the cancer markers and that we were waiting for a CT. They understood our dilemma - they had seen the same thing happen with Mrs G's brother. He too had been a mystery, until three days before his death when he had been diagnosed with a sort of cancer - they were not sure which. My SHO counselled them about the need for a PM and gained their consent.
Two days later, the infectious disease consultant dropped by to say that he had attended the post mortem. They had found deposits of cancerous cells in her liver, lung and spine, but could not find the primary source. Had Mrs G had the CT it would not have made an iota of a difference. Prior to her death, we were actively treating her with intravenous antibiotics, but we were also making sure that she was comfortable. Had we known about the widespread cancer, we would have done the same, to ensure a peaceful death.
The morning before I found out the results of the PM, Mrs G's son came by, with a big tin of chocolate and a thank you card. I found it incredible that despite the grief the family must be going through - not only with the death of a loved one, but also the unfortunately necessary defilement of the body - they were still grateful for the care that she had recieved.
I had spent a lot of time with Mrs G - examining her, taking blood from her, and just nattering, although it was mostly a soliloquey - she was usually too drowsy/confused to answer.
The chocolate tasted like ashes.

*bone scan - one of the many tests done by nuclear medicine, using a radioactive isotope - in the case of a bone scan, the isotope goes to areas of increased calcium uptake, which is where there is more bone production - so if there are metastases causing increased bone growth, it shows up as a hot spot.
**iv contrast means that blood provides a contrast, so if there has been a bleed (or conversely a lack of blood supply), or if there is a tumour with a rich blood supply it will be more prominent, than if no contrast had been used.
***there is no evidence for this, but my hospital's protocol states that it should be used to prevent contrast nephropathy.
****V/Q scan - another nuclear medicine scan - this time using a two isotopes - one which is inhaled and another which is injected into the blood stream. A difference between images taken of the chest with each isotope suggests a pulmonary embolus (fancy term for clot in the lung).