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Multiple Feedings of the Mind- Palliative Care Pearls

Multiple Feedings of the Mind- Palliative Care Pearls. Department of Medicine Grand Rounds January 29, 2010. Case. JG is a 32 year old woman who presented to JMC in 2001 (at the age of 23) with an an enlarging right sided breast mass.

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Multiple Feedings of the Mind- Palliative Care Pearls

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  1. Multiple Feedings of the Mind-Palliative Care Pearls Department of Medicine Grand Rounds January 29, 2010

  2. Case • JG is a 32 year old woman who presented to JMC in 2001 (at the age of 23) with an an enlarging right sided breast mass. • Biopsy diagnosed invasive ductal adenocarcinoma, ER/PR+, Her2-. Pt received subtotal mastectomy and adjuvant chemo/XRT, and tamoxifen. • BrCA2 positive.

  3. In 2007 pt complains of diffuse back pain an LLE numbness and weakness. • Diffuse bony mets, cauda equina syndrome diagnosed. • XRT and hormonal therapy initiated with good symptomatic response. • Followed in oncology clinic

  4. Liver, brain (pachymeninges, base of skull), bone marrow, and lung metastases noted in 2008. • Functional status decline over the ensuing months. • Pt is admitted in November 2008 due to nausea, headache, and abdominal pain.

  5. Exam notable for: • A&O X 3. Pleasant, conversant, aware. • Cachexia • Tachypnea • Dullness to percussion ½ up lungs. • Bony tenderness along ribs and femur • Abdominal tenderness without rebound

  6. Hypercalcemia 12.1 • Pain crisis likely multifactorial-from pathologic fractures of femur, spine, and ribs in addition to visceral mets. • Dyspnea from marked pleural effusions and compression atelectasis.

  7. Pt rx’d for hypercalcemia with i.v.f. and pamidronate. • Given morphine for pain and reglan for nausea.

  8. Despite having had 7 years of contact with our medical system, over 50 visits to oncology clinic and 12 admissions to the hospital, there was no documented discussion with this chronically critically ill, actively dying patient regarding end of life matters.

  9. “Goals of Care”

  10. Palliative care called because “the patient refuses to be DNR.”

  11. Scenario #1

  12. Scenario #2

  13. How to have a DNR discussion Step #1: Establish the setting • Comfortable and private • Turn off beeper • Sit down! Butt in chair. Level eye contact. • “I need to discuss some serious medical issues. Would you want anyone else here when we have this conversation?” • “I’d like to talk about some health decisions that will need to be made in the near future.”

  14. Step #2: What does the patient/family know? • “What is your understanding of your illness?” • “What do you understand about your health situation based on what the doctors have told you?” • Open ended. Allow the patient to talk. • If the patient doesn’t really know what is going on, ask: • Do they want to hear the information themselves. • Do they want to designate someone else to hear the information and make the decisions for them.

  15. Step #3: What does the patient expect to happen? • “What are your hopes for the future?” • “Have you thought about how you want things to be if you became more ill?” • Gives you a sense of person’s values and priorities • Opportunity to identify unlikely expectations. • Gently clarify what is likely or unlikely to happen.

  16. Step #4: Discuss resuscitation • “How do you want things to be when you die?” • “If you were to die while in the hospital would you want us to keep you comfortable and allow nature to take its course? Another alternative would be to attempt resuscitation…” • “If you should die despite all of our efforts, would you want to pass on naturally or would you want us to consider “heroic measures” such as CPR to try to bring you back? • Clarify misconceptions about CPR

  17. Survival to Hospital Discharge after In-Hospital CPR, According to Year and Race Ehlenbach WJ et al. N Engl J Med 2009;361:22-31

  18. Step #5: Offer your recommendation • “From what you’ve told me I think it would be best if I placed a Do Not Attempt Resuscitation order on the chart.” • “You are saying that you want to fight the cancer, but when the time comes you want to die peacefully. I recommend that we put a DNR order in the chart.” • “We will continue maximal medical therapy. However, if you die despite everything, we won’t use CPR to bring you back.”

  19. Use the word “die.” CPR is not like jump starting your car. Do not say: “Do you want us to do everything?” Too vague and misleading. DNR ≠ stopping efforts to cure patient. Patients and families are ill served by offering them all possible therapies as if picking dishes from a menu. Help guide them. Opportunity to appoint Health Proxy.

  20. Scenario Revisited

  21. Case continued • The patient’s pain is improved with escalating doses of morphine and gabapentin. • She develops fever, worsening dyspnea, and a new infiltrate on CXR. Broad spectrum antibiotics are started for a presumed hospital acquired PNA.

  22. The patient’s respiratory status continues to decline. The patient will likely suffer an imminent respiratory arrest if not mechanically intubated. What’s the plan?

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