Brain Mets or Psych?

An advanced cancer patient refusing treatment, presents all sorts of problems for family and providers. Compound this with bizarre psychiatric symptoms and contrary behavior and you have legal and ethical challenges as well. The first thing one does is order a psych consult, a tenuous diagnosis, even commitment, in the extreme, restraints. This Perspective Articlre in NEJM describes such a dilemma. Dec 8 375 2220-2221 DOI 10.1056/NEJp 1612129

My first rotation as a junior medical student -- UMichMed '60 in "Old Main," a 2000 bed hospital with 20 bed wards -- was "Blue Female" 2nd floor east, exclusively advanced breast cancer. Each ward had its own personality, largely driven by the nursing staff and the patients themselves. Blue. Female's was one of mutual support and suprising spirit; they shared in one another's condition, complications, prognosis and listened through the curtains to one another's daily rounds. Despite turnover and a frequent empty bed, you could feel the strength and moral.

Not infrequently, however one or two would become recalcitrant, atgumentive and display bizarre ideation. Residents and young professors, new to Blue Female, would invariably order a psych consult and speculate over which psych diagnosis. We did not have MRI, but everyone in the ward knew the problem was metastice to brain, even the ward clerk who did not rotate. We did not need an MRI or for that matter a psychiatrist who usually failed to figure it out.

Not long ago, I listened to an ethicist presentation of an almost identical case to the one in the NEJ. The case involved court orders for treatment and, early on, a court ordered confinement for psychiatric care and family guilt. No one thought to order an MRI.

Sadly we have losst the beauty of bedside teaching, supportive wards when support is needed the most and that's not to mention autopsy which would indeed figure it out, without the family having to say, she went crazy in the end.