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Teachable Moment
Less Is More
January 2016

Surgical Intervention in Terminal Illness—Doing EverythingA Teachable Moment

Author Affiliations
  • 1Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
JAMA Intern Med. 2016;176(1):18-19. doi:10.1001/jamainternmed.2015.6335

There comes a time for all of us when we must shift our efforts from focusing on more time to focusing on everything else.1

Atul Gawande

A man in his late 70s with dementia, oriented but unable to make complex medical decisions, presented with confusion, focal right-sided weakness, and hypoxemia. He was taking lifelong anticoagulation medication for recurrent deep venous thrombosis but was receiving subtherapeutic doses on presentation. A stroke alert was called, and imaging revealed a discrete mass measuring 3.4 × 5.1 × 6.0 cm in the left parietal lobe and another measuring 1.7 × 1.7 × 2.1 cm in the superior cerebellum, concerning for brain metastases. Computed tomographic angiography of the chest revealed a subsegmental pulmonary embolism, and a heparin drip was started. Subsequent evaluation revealed widely metastatic lung cancer. Biopsy confirmed adenocarcinoma with a molecular genetic profile not favorable to chemotherapy. Radiation oncologists recommended against radiation therapy because the brain masses were too large. Neurosurgeons offered palliative resection of the brain masses.

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