The following cases and commentary, which focus on care for patients at the end of life, are excerpted from ACP's Medical Knowledge Self-Assessment Program (MKSAP 16).
Case 1: New diagnosis of advanced cancer
A 67-year-old woman is admitted to the hospital with shortness of breath and is found to have a pulmonary embolus. She is begun on low-molecular-weight heparin. Upon further evaluation, a large left breast mass is found along with a malignant left-sided pleural effusion. Biopsy of the breast mass reveals poorly differentiated adenocarcinoma. Although she has a limited social support system and minimal understanding of her disease, she is interested in evaluating possible treatment options for her condition. She continues to have mild shortness of breath and marked anxiety related to her newly diagnosed condition, but otherwise feels well.
In addition to oncology and surgery consultations, which of the following is the most appropriate next step in this patient's care?
A. Antidepressant therapy
B. Hospice care referral
C. Long-acting morphine
D. Palliative care consultation
Case 2: Myocardial infarction with DNR status
A 90-year-old woman is admitted to the hospital for the evaluation of chest pain. She describes the pain as pressure within the midchest with radiation to the neck. During the past week, she has had several episodes at rest, with 2 episodes in the last 24 hours for which she took aspirin. She is currently free of pain. Last week she met with her general internist to discuss end-of-life issues and decided upon do-not-resuscitate (DNR) status and does not want invasive procedures performed to prolong her life. She is amenable to medical therapy for potentially reversible conditions. Her medications are aspirin, a multivitamin, and docusate.
On physical examination, temperature is normal, blood pressure is 140/80 mm Hg, pulse rate is 72/min, and respiration rate is 11/min. BMI is 20. A normal carotid upstroke without carotid bruits is noted, jugular venous pulsations are normal, and normal S1 and S2 are heard without murmurs. Distal pulses are normal and no peripheral edema is present.
Serum troponin level is elevated. Electrocardiogram displays a sinus rhythm at 70/min, T-wave inversion in leads V4 through V6, and no Q waves.
In addition to aspirin and low-molecular-weight heparin, which of the following is the most appropriate treatment?
B. Diltiazem, atorvastatin and clopidogrel
D. Metoprolol, atorvastatin and clopidogrel
Case 3: Family faced with care decisions
A 97-year-old woman was hospitalized with jaundice, abdominal pain, weight loss, nausea, and intermittent vomiting 1 week ago. She was found to have poorly differentiated metastatic pancreatic adenocarcinoma. She lives with her daughter. Current medications are morphine, a stool softener, and a laxative. On physical examination, vital signs are normal. She is a depressed-appearing woman in no distress who appears cachectic but comfortable.
During bedside discussions, the patient has deferred all medical decision-making to her family. They have asked that “everything be done” and have declined to place the patient on do-not-resuscitate status. They have requested that a surgeon be consulted to remove the cancer and that an oncologist be consulted for initiation of chemotherapy. The health care team has arranged a family meeting to address end-of-life care.
Which of the following is the best initial communication strategy for the family meeting?
A. Ask the patient's opinion about an advanced directive
B. Explain that curative therapy is futile
C. Explain the diagnosis and the prognosis
D. Explore the family's understanding about the patient's condition
Case 4: Palliative care for dyspnea
An 88-year-old man in hospice care is evaluated for dyspnea. He has advanced dementia, severe COPD, and coronary artery disease. Based on prior discussions with his family regarding the goals of care, it was decided that his treatment should consist of comfort care measures only. All of his medications except as-needed albuterol and ipratropium have been discontinued.
On physical examination, he is afebrile, blood pressure is 108/76 mm Hg, pulse rate is 110/min, and respiration rate is 26/min. Oxygen saturation is satisfactory. He is cachectic and tachypneic and is disoriented and in moderate respiratory distress. Heart sounds are distant and tachycardic but an S3 is not present. Chest examination reveals decreased breath sounds as well as diffuse, fine inspiratory crackles consistent with prior examinations. Extremities are warm and dry.
In addition to continuing his bronchodilator therapy, which of the following is the most appropriate next step in the treatment of this patient?
A. Ceftriaxone and azithromycin
Answers and commentary
Correct answer: D. Palliative care consultation.
In this patient with a newly diagnosed advanced malignancy, palliative care consultation is an important component of her care. Palliative care focuses on improving and maintaining the quality of life in individuals with any severe illness. Palliative care is a multidisciplinary, boarded specialty that focuses on preventing and relieving suffering and establishing goals of treatment that are consistent with the patient's wishes. This often involves efforts at pain and symptom control and encouraging and enabling patients to be actively involved in the decisions regarding their care. Nonhospice palliative care does not exclude testing, treatment, or hospitalization, but seeks to ensure that these interventions are consistent with what the patient wants and the expected goals and outcomes of care. Whereas care in a hospice setting may be palliative in nature, not all palliative care takes place in patients with terminal illness. Palliative care input may be particularly valuable in assisting this patient, who has a new diagnosis of severe disease, with understanding her illness and making key decisions regarding her care. Although studies are limited, palliative care has been shown to improve overall quality of life in the setting of various diseases relative to usual care for severely ill individuals.
Although depression may be seen in some patients with severe illness, starting therapy for depression without clear evidence the patient is having significant depressive symptoms or that pharmacologic treatment is indicated would be inappropriate.
It is not clear that this patient is either medically or emotionally ready for hospice care. Although her newly diagnosed malignancy may carry a poor prognosis, her currently stable condition and expressed desire to explore possible treatment options would make a decision to pursue hospice care premature without further characterization of her disease and discussion of her long-term treatment goals.
Opioid therapy is commonly used in cancers and particularly malignancies involving the respiratory tract to reduce both pain and dyspnea. However, this patient does not have significant pain and has only mild shortness of breath, which should improve as her pulmonary embolism resolves. Therefore, initiation of ongoing opioid therapy is not indicated.
- Palliative care focuses on improving and maintaining the quality of life in any patient with severe illness; it is not limited to those with terminal illness or inpatient settings.
Correct answer: D. Metoprolol, atorvastatin and clopidogrel.
This patient should begin taking a β-blocker, a statin, and clopidogrel, in addition to aspirin and low-molecular-weight heparin. Her chest pain, T-wave inversions in the lateral leads of the electrocardiogram, and elevated cardiac biomarkers are consistent with a non-ST-elevation myocardial infarction (NSTEMI). The TIMI risk score is 4 (age >65 years, elevated troponin level on presentation, aspirin use, and two angina episodes in the last 24 hours), indicating an intermediate-risk NSTEMI. She is elderly, and she recently established do-not-resuscitate (DNR) status and a request to avoid invasive procedures; therefore, she is not a candidate for invasive angiography.
Appropriate medical therapy for NSTEMI includes antiplatelet agents (aspirin and clopidogrel) and a β-blocker. In addition, patients require antithrombin therapy with either unfractionated heparin or low-molecular-weight heparin and high-dose statin therapy. Randomized trials have shown a benefit of low-molecular-weight heparin over unfractionated heparin with a reduction in death and recurrent myocardial infarction. Contraindications to low-molecular-weight heparin include kidney dysfunction, obesity, and the need for invasive procedures.
Oral β-blockers are first-line agents for treating a NSTEMI. A calcium channel blocker such as diltiazem can be used in patients with a contraindication to β-blockers and in those with continued angina despite optimal doses of β-blockers and nitrates. Contraindications to β-blockers include advanced heart block, heart failure, and reactive airways disease. This patient does not have contraindications to β-blockers, so diltiazem would not be the preferred treatment.
- Patients with a non-ST-elevation myocardial infarction and an intermediate TIMI risk score should be treated with antiplatelet agents (aspirin and clopidogrel), a β-blocker, high-dose statin therapy, and antithrombin therapy with either unfractionated heparin or low-molecular-weight heparin.
Correct answer: D. Explore the family's understanding about the patient's condition.
The cornerstone of establishing goals of care in the end-of-life setting is to communicate in a patient-centered, open-ended format. This is true regardless of whether a patient or patient's family is angry or is requesting inappropriately aggressive care. The first step in this process in this case is to ask the family to tell you what they understand about the patient's condition. Active, empathic listening allows the caregiver to establish what the patient and family understand about the diagnosis and prognosis. It also shows respect for the myriad ways in which loved ones process information about medical conditions and helps to establish trust. The family should be allowed to vent their frustration and to articulate what they believe the patient's condition and chance of meaningful recovery to be. Given the feelings of distress about the patient's condition, it is entirely possible that one meeting may not be enough to establish clearly defined goals of care. Asking open-ended questions and being comfortable with silences are important in building a trusting relationship with the patient and family.
The upcoming dialogue with the family is likely to be emotionally charged, and a series of visits may be needed to cover all appropriate areas. It would not be appropriate to initiate the discussion with the patient and family about advanced directives until it is learned what the family knows about the diagnosis and prognosis.
It would not be helpful to begin a meeting with a distraught family or patient by stating curative therapy would be futile. This approach is likely to further alienate a family struggling with a distressing diagnosis.
Although explaining the diagnosis and prognosis may be an important goal for a family meeting, it is usually more effective to begin the meeting with an open-ended question that allows the physician to better understand the family's perspective. Explanations can then be better tailored to what the family knows and understands about the patient's condition.
- The cornerstone of establishing goals of care in the end-of-life setting is to communicate in a patient-centered, open-ended format.
Correct answer: D. Morphine.
This patient on comfort care should be given morphine. Dyspnea is one of the most common symptoms encountered in palliative care. It is most often the result of direct cardiothoracic pathology, such as pleural effusion, heart failure, COPD, pulmonary embolism, pneumonia, or lung metastases. Dyspnea can also be caused by systemic conditions, such as anemia, muscle weakness, or conditions causing abdominal distention. Patients with underlying lung disease on bronchodilator therapy should have this therapy continued to maintain comfort. Opioids are effective in reducing dyspnea in patients with underlying cardiopulmonary disease and malignancy. In patients already receiving opioids, using the breakthrough pain dose for dyspnea and increasing this dose by 25% if not fully effective may be helpful. A 5-mg dose of oral morphine given four times daily has been shown to help relieve dyspnea in patients with end-stage heart failure. Low-dose (20 mg) extended-release morphine given daily has been used to relieve dyspnea in patients with advanced COPD.
Antibiotics and corticosteroids are appropriately used in patients with exacerbations of severe COPD. However, neither would be expected to provide immediate relief of the patient's respiratory distress and would also be inconsistent with care focusing primarily on comfort measures at the end of life.
In contrast to opioids, benzodiazepines have not demonstrated consistent benefit in treating dyspnea. However, they may be useful in specific patients who have significant anxiety associated with their dyspnea.
- Opioids are effective in reducing dyspnea in patients with underlying cardiopulmonary disease and malignancy.