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A 75-year-old man complained of constant upper-left lateral thoracic pain. He said he had fallen from his bicycle shortly before the onset of symptoms and attributed the pain to the fall. Physical examination was unrevealing. Rib films showed no abnormality, and he was treated with aspirin. When he was seen again one month later, the pain had not abated. His medication was changed to ibuprofen, again without total relief. A chest film at this time was normal.

For the next six months, the pain waxed and waned but was generally tolerable. The patient did not lose weight and, aside from weakness and mild dyspnea, did not complain of other symptoms.

When the pain suddenly worsened, another chest film was taken, which showed a pleural mass and effusion in the upper left thorax. At this point, the patient revealed that in 1937, he had been employed for 30 days as a lathe operator working on high-pressure pipes that contained asbestos. Pleural biopsy confirmed the diagnosis of malignant mesothelioma.

Because of a recent myocardial infarction and worsening coronary artery disease, he was not a surgical candidate. Faced with the diagnosis, the patient entered a prolonged period of denial. A family conference was held, and the diagnosis, prognosis and practical options open to the patient were frankly discussed.

When the patient accepted the diagnosis and the inevitability of death, he executed a durable power of attorney for health care, completed a will and made other financial decisions important to his family. He chose not to undergo chemotherapy or radiation therapy.

The patient’s care was managed at home with the assistance of visiting hospice nurses and family counseling. He died three and one-half months after the diagnosis of mesothelioma was made.