End-of-life care: when chemotherapy may not be the best option

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http://www.hemonctoday.com/article.aspx?rID=26227

A 62-year-old man presented to the emergency room with jaundice, abdominal

pain, hypercalcemia and respiratory distress. He had been undergoing

outpatient evaluation of a lung mass for the previous two months. Laboratory

studies suggested impending liver failure with a lactate of 14 mg/dL and a

serum ammonia of 112 mcmol/L, bilirubin of 12.7 mcmol/L, and transaminases

two to three times normal.

The patient's performance status was ECOG 4 (in bed more than 50% of the

time), and he was ambulatory prior to presentation. He was treated with

oxygen, IV fluids, and parenteral and nebulized opioids. The patient was

more comfortable but increasingly lethargic. He and his spouse wished for

aggressive treatment, including cardiopulmonary resuscitation, pending

diagnostic evaluation. A liver biopsy had revealed small cell carcinoma.

Two physicians are involved in this case: Dr. O: a medical oncologist,

50-ish, with 20 years of experience treating patients with solid tumors; and

Dr. PC: palliative care specialist, 30-ish, expert in pain and symptom

management, patient decision-making and ethics.

Can they collaborate?

J.

Dr. O: I saw the patient, discussed goals of care, and was frank about the

situation. I told him he had a small chance of the cancer shrinking, days to

live if he declined chemo, and a few months to live if he got chemo and the

cancer shrank. The side effects of chemotherapy were relatively mild and if

the chemotherapy did not work, he would be dead before he got neutropenic or

had worsening liver failure.

I was torn because small cell lung cancer often shrinks dramatically with

chemotherapy, even when the patient has poor performance status, liver

failure and lactic acidosis. Chemotherapy would likely not make symptoms

worse in the short term.

Dr. PC: The palliative care team discussed goals of care and reviewed

therapeutic options. We felt he had a small chance of the cancer responding

to chemo but were concerned he might not tolerate chemo given his liver

failure. He likely had days to weeks to live if the cancer did not shrink or

if he declined chemotherapy. He might have a few weeks to a few months to

live if he got chemotherapy, the cancer shrank, and his liver failure

improved.

The patient understood the prognosis and was emphatic: " I don't want to die

like my daddy did in the hospital. I want to go home. "

Other issues

The nurses were concerned about the wife's ability to provide adequate

physical care alone, as the mordidly obese patient required the assistance

of three.

To read the entire article click on link above.

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