End-of-Life Issues

End-of-Life Issues: Case 2

Angela is a 72-year-old woman with end stage congestive heart failure from coronary artery disease--she has had two myocardial infarctions. When her medical management is optimal, she is just able to take care of herself in her own apartment, but with any small decompensation, she ends up in the hospital. She comes in for a clinic visit, and her weight is up 2 kilograms and she is complaining of paroxysmal nocturnal dyspnea, even though she has been taking her meds as prescribed. Exasperated and discouraged, she asks, "Am I dying?".

End-of-Life Issues: Case 1

Skip is a 50-year-old man with metastatic nonsmall cell lung cancer. He decided to try palliative chemotherapy because "otherwise I might just as well roll over and give up." After the first cycle of carboplatin and taxol, he requires hospitalization for fever and neutropenia (a complication of the chemotherapy). You stop by for a visit, and he says he feels terrible, wonders "if the chemo is worth all this", but that he's too scared to stop.

CASE STUDIES

Skip is a 50-year-old man with metastatic nonsmall cell lung cancer. He decided to try palliative chemotherapy because "otherwise I might just as well roll over and give up." After the first cycle of carboplatin and taxol, he requires hospitalization for fever and neutropenia (a complication of the chemotherapy). You stop by for a visit, and he says he feels terrible, wonders "if the chemo is worth all this", but that he's too scared to stop.

Case Discussion

For metastatic non small cell lung cancer, palliative chemotherapy is an intervention providing, on average, a small benefit at considerable toxicity (a consideration for the Medical Indications box in a Clinical Ethics 4-box analysis). Yet for a patient who is well informed, understands the benefits and burdens, and wishes to proceed, a trial of palliative chemotherapy is justified. However, now Skip is voicing concern: the most important thing to do is hear him out. Find out what he is worried about, how he rates his quality of life, and what his goals are. This information will help you sort out what is going through his mind and help you guide him to a decision that will be the best for him.

As Skip thinks through his situation, ask him if he wants you to describe what would happen if he decides to have more chemotherapy, or stops his chemo and starts hospice care. Eventually you might ask him what a good death would be for him--he may not be able to answer immediately, but it might help him (and you) shape a care plan later. When you talk with Skip, keep in mind the goals for a decent death.

Angela is a 72-year-old woman with end stage congestive heart failure from coronary artery disease--she has had two myocardial infarctions. When her medical management is optimal, she is just able to take care of herself in her own apartment, but with any small decompensation, she ends up in the hospital. She comes in for a clinic visit, and her weight is up 2 kilograms and she is complaining of paroxysmal nocturnal dyspnea, even though she has been taking her meds as prescribed. Exasperated and discouraged, she asks, "Am I dying?". The cardiologist replies: "Well, no--this is all reversible."

What would you say?

Case Discussion

The SUPPORT study has shown us that the clinical course of dying from congestive heart failure is quite different from dying of lung cancer. Patients with lung cancer begin a visible, predictable decline several weeks before death that usually evident to experienced clinicians. Patients with congestive heart failure, however, experience periods of fairly good function alternating with decompensation right up until death, and the terminal event for these patients is often sudden. This pattern of decline is not usually labeled by patients or physicians as "dying." The unpredictable course has resulted in very few hospice referrals for patients with end-stage congestive heart failure.

The best care plan in this situation would be based on a discussion with Angela about what kinds of contingency plans should be in place if she has a severe, possibly fatal decompensation (see Advance Care Planning). Some medical centers are developing Palliative Care or Comfort Care services to try to better match the needs of patients with less predictable end-stage illnesses.