Truth Is a Delicate Issue

Can truth harm--or even kill--a patient?

I never used to think so. In fact for years, having watched senior colleagues sometimes withhold truth, I held another view. Namely, that competent adults deserved to know every detail of their medical case.

Then I met Sarah.

Sarah was a respectable, well-groomed woman in her mid-60s. She lived alone, had no children and was a frequent patient at the hospital and clinic. High blood pressure and an aortic aneurysm--a balloon-like swelling of the body’s largest artery--were her main ailments.

But blood pressure and an aneurysm weren’t what wakened Sarah in the night and sent her racing to the emergency room. It was pain, striking out of the blue and coursing through her body like a current, that brought her here.

Sarah’s pain baffled her doctors as they attempted time and again to determine its cause. They requested consults. They ordered tests. They even considered operating on her aorta where it curved over her heart like a massive arch. Although the surgery might forestall a fatal rupture, it was unclear whether it would ease Sarah’s attacks. In the end, that plan was scuttled as too risky a gamble.

One night, Sarah was again admitted to the hospital for severe pain. That month, I was assigned to the ward as a supervising doctor. Legally, Sarah was my patient. When I heard her story, as a specialist in the treatment of infectious diseases, bells rang.

*

Let’s go look at her chest X-ray, I urged the interns and resident. I have a hunch this patient has syphilis.

Sure enough, the chest X-ray showed a sausage-like dilation of the aorta where it exits the heart. A textbook image 50 years ago, but rare today, now that syphilis patients are diagnosed and treated earlier. Now Sarah’s pain made sense, too. After decades, syphilis can damage not only blood vessels but spinal nerves. The result, in some cases, is lightning-like pain.

Like a bulldog straining on a leash, I couldn’t wait to get to work. And for good reason. If Sarah had syphilis, antibiotics might halt the damage. But first we needed to confirm her diagnosis. Even before that, I decided, I needed to speak with her frankly.

Sarah, now medicated and settled in bed, seemed happy to chat. Tentatively, I began. Long ago, did she ever have a positive Wasserman reaction? I ventured. Possibly some injections for a sexual disease? Sarah caught my drift. Back in the ‘50s, she responded, her boyfriend had played around. And yes, before she broke it off, a doctor tried to give her penicillin shots. But because the shots gave her hives, she took a weaker antibiotic instead.

The mystery was solved. I explained my theory. That she picked up syphilis long ago. That even now it could be causing her pain. That although her previous treatment hadn’t worked, modern drugs could help. All we needed to do now was a blood test. Oh yes, and a head scan and a spinal tap to look for brain inflammation, because that would also affect our treatment.

*

Sarah’s face, previously calm and trusting, darkened with anger. There’s nothing wrong with my brain, she retorted. Go away. I don’t want to talk any more.

Later that day I tried again to cajole Sarah into taking the tests and starting treatment. She would hear none of it, and because she had no family, there was no court of appeal. That afternoon, well enough to call her own cab, she left the hospital against medical advice. The following day, Sarah’s blood test results came back: syphilis. But by then it was too late. Early that morning she died at home, alone.

I’ll never know if our conversation precipitated Sarah’s death, but it’s possible. Maybe it unearthed long-buried memories and fears. That stress, combined with high blood pressure and weakened arteries, could have triggered a stroke or heart attack.

All I really know is this. Given a second chance, I would have withheld Sarah’s diagnosis, or at least presented it to her in stages.

Looking back, I think I was overcome by my zeal to treat a rare disease that doctors seldom see these days. Along the way, I forgot the patient.

In my medical lifetime, we’ve shifted from paternalism to more of a partnership between doctors and patients. Overall, a good change. But partnership has its price. Sometimes, it seems, hearing the whole truth hurts patients rather than helps them.

* Claire Panosian Dunavan is a Los Angeles internist and specialist in the treatment of infectious diseases. Reader comments are welcome at: cpanosian@mednet.ucla.edu.

* The Doctor Files runs the fourth Monday of the month in Health.