offering hope to the patient with end stage disease jason corbeill pa-c

Offering Hope to the Patient Offering Hope to the Patient With End Stage Disease With End Stage Disease

Jason Corbeill PA-CJason Corbeill PA-C

““I’ve got bad news…”I’ve got bad news…”

Tell them what you have found and then be quiet. Be Tell them what you have found and then be quiet. Be patient. Wait. Shut your mouth. Shh.patient. Wait. Shut your mouth. Shh.

Do not lie.Do not lie. Do not sugarcoat the truth.Do not sugarcoat the truth. It is ok to leave the details (i.e. prognosis, etc) till It is ok to leave the details (i.e. prognosis, etc) till

later appointment if the patient agrees.later appointment if the patient agrees. Ask patient what they want to knowAsk patient what they want to know It may be helpful to have family member or friend present.It may be helpful to have family member or friend present.


They need to know if the disease is curable or They need to know if the disease is curable or notnot

Offer hope in some form.Offer hope in some form. If not for cure, then for control of disease or If not for cure, then for control of disease or

management of symptomsmanagement of symptoms Most patients are scared of the dying process and Most patients are scared of the dying process and

it’s symptoms (pain, sob, etc) rather than dying.it’s symptoms (pain, sob, etc) rather than dying.


Be empatheticBe empathetic ListenListen

Sometimes the patient comes to terms with the Sometimes the patient comes to terms with the diagnosis by hearing themselves talk about it with diagnosis by hearing themselves talk about it with youyou


When told of incurable disease, many patients When told of incurable disease, many patients will recap their lives.will recap their lives.

They will speak of their families, They will speak of their families, achievements, faith, the good times.achievements, faith, the good times. Encourage this.Encourage this.


Some patients will then worry about the ones Some patients will then worry about the ones they are leaving behind.they are leaving behind. Especially the young mother/father.Especially the young mother/father. Be quiet and listen.Be quiet and listen. It’s ok to tear up.It’s ok to tear up. There may be a ton of social issues.There may be a ton of social issues.

Advanced directive, POA, will, finances, Advanced directive, POA, will, finances, unaccomplished dreams, family dynamics…unaccomplished dreams, family dynamics…


PrognosticatingPrognosticating Ask them if they want to knowAsk them if they want to know Most will (or their families)Most will (or their families) Truth is, you don’t knowTruth is, you don’t know

Think of the stats, previous patients, etc.Think of the stats, previous patients, etc. Days to weeks, weeks to months, months to years…Days to weeks, weeks to months, months to years… Time is now precious!Time is now precious!

Comfort Measures at homeComfort Measures at home

SeizuresSeizures Those with brain lesions at riskThose with brain lesions at risk

Continue keppra/phenytoin, etc while able to take Continue keppra/phenytoin, etc while able to take oral meds.oral meds.

Use liquid ativan or suppository prn when unable Use liquid ativan or suppository prn when unable to take adequate po.to take adequate po.

steroidssteroids


NauseaNausea Patients with abdominal/pelvic cancers at Patients with abdominal/pelvic cancers at

highest riskhighest risk Ondansetron ODT (Zofran)Ondansetron ODT (Zofran) Haloperidol (Haldol) liquid concentrateHaloperidol (Haldol) liquid concentrate Lorazepam (Ativan) liquidLorazepam (Ativan) liquid Venting G tubeVenting G tube OctreotideOctreotide Therapeutic paracentesisTherapeutic paracentesis


Shortness of breath/air hungerShortness of breath/air hunger Lung cancer patients, lung metastases patients.Lung cancer patients, lung metastases patients. Ultimately most patientsUltimately most patients

Low dose morphine 2mg prnLow dose morphine 2mg prn OxygenOxygen MorphineMorphine ScopolomineScopolomine Pleurx catheter if recurrent pleural effusionPleurx catheter if recurrent pleural effusion


PainPain NarcoticsNarcotics

Several delivery mechanismsSeveral delivery mechanisms TabletsTablets IV drips (PCA-patient controlled analgesia) via IV drips (PCA-patient controlled analgesia) via

mediports or subcutaneous buttonsmediports or subcutaneous buttons Liquid narcotics orallyLiquid narcotics orally Patches (fentanyl)Patches (fentanyl) Palliative radiationPalliative radiation


Pain (continued)Pain (continued) Steroids (decadron)Steroids (decadron) BisphosphonatesBisphosphonates Epidural catheter pumpEpidural catheter pump


DepressionDepression Drug of choiceDrug of choice


Nutrition issues:Nutrition issues: Many end stage cancer patients don’t eatMany end stage cancer patients don’t eat

Early satietyEarly satiety NauseaNausea No appetiteNo appetite Inability to swallow/risk of aspirationInability to swallow/risk of aspiration

Comfort feedsComfort feeds


Nutrition issues:Nutrition issues: TPN has no role in end stage cancerTPN has no role in end stage cancer Tube feedsTube feeds Patients don’t feel hungryPatients don’t feel hungry

Usually upsets family more than patientUsually upsets family more than patient

Getting HelpGetting Help

Palliative MedicinePalliative Medicine Transitional careTransitional care Hospice careHospice care

Case 1Case 1

62 y/o male presents to ED with headache, 62 y/o male presents to ED with headache, mental status changes.mental status changes.

CT brain reveals tumor with surrounding CT brain reveals tumor with surrounding edema in right parietal lobeedema in right parietal lobe

MRI confirms, there is mild midline shiftMRI confirms, there is mild midline shift

Case 1Case 1

As the oncology PA on call you are summoned As the oncology PA on call you are summoned to the ED to speak with patient and family.to the ED to speak with patient and family.

What do you say?What do you say? IV decadron statIV decadron stat Neurosurgery is consulted and subtotal Neurosurgery is consulted and subtotal

resection is performed confirming diagnosis of resection is performed confirming diagnosis of GBM.GBM.

What do you say now?What do you say now?

Case 1Case 1

Patient begins Temodar and whole brain Patient begins Temodar and whole brain radiation therapy.radiation therapy.

6 mos into his therapy he presents with new 6 mos into his therapy he presents with new onset seizuresonset seizures

MRI confirms progression of disease now with MRI confirms progression of disease now with new nodules in contralateral brain.new nodules in contralateral brain.

Neurosurgery will not operate.Neurosurgery will not operate. No more XRTNo more XRT

Case 1Case 1

Goes on 2Goes on 2ndnd line chemotherapy with avastin. line chemotherapy with avastin. Performance status decreases.Performance status decreases. Presents with confusion 6 mos laterPresents with confusion 6 mos later CT/MRI repeated and shows increasing CT/MRI repeated and shows increasing

disease with edemadisease with edema His decadron dose is increased.His decadron dose is increased.

Case 1Case 1

It is clear his disease is progressingIt is clear his disease is progressing What do you say now?What do you say now? Do you have anything to offer this patient?Do you have anything to offer this patient?

Case 2Case 2

35 y/o female presents to your office with 35 y/o female presents to your office with lump in breast on self-examlump in breast on self-exam

Referred for biopsy which shows infiltrating Referred for biopsy which shows infiltrating ductal carcinoma, high grade. A staging CT ductal carcinoma, high grade. A staging CT shows metastases to liver and lung.shows metastases to liver and lung.

She goes on chemotherapy x.She goes on chemotherapy x.

Case 2Case 2

6 mos later she presents with progressive sob, 6 mos later she presents with progressive sob, doe.doe.

CXR shows bilat infiltrate, diffuse. A CT CXR shows bilat infiltrate, diffuse. A CT rules out PE but shows bilat infiltrate rules out PE but shows bilat infiltrate consistent with lymphangetic spread.consistent with lymphangetic spread.

Steroids are startedSteroids are started Morphine is given.Morphine is given. 22ndnd line chemotherapy started. line chemotherapy started.

Case 2Case 2

Presents months later with left sided weakness.Presents months later with left sided weakness. CT brain shows lesion right parietal area CT brain shows lesion right parietal area

confirmed with MRI.confirmed with MRI. Referred to radiation oncology and undergoes Referred to radiation oncology and undergoes

radiation therapy x 20 treatments.radiation therapy x 20 treatments.

Case 2Case 2

Post radiation, her performance status Post radiation, her performance status declines.declines.

Restaging CT scans show progression in lung, Restaging CT scans show progression in lung, brain and now liver as well.brain and now liver as well.

She is no longer a candidate for chemotherapy.She is no longer a candidate for chemotherapy. Do you have any thing to offer this patient?Do you have any thing to offer this patient?

Case 3Case 3

68 y/o male diagnosed with colon CA.68 y/o male diagnosed with colon CA. Starts chemotherapy and does well.Starts chemotherapy and does well. Unfortunately, restaging CT scans after 6 Unfortunately, restaging CT scans after 6

cycles chemotherapy show new liver disease.cycles chemotherapy show new liver disease. 22ndnd line chemotherapy x 4 cycles. line chemotherapy x 4 cycles. Restaging CT shows progressive disease in Restaging CT shows progressive disease in

liver and omental metastases. liver and omental metastases.

Case 3Case 3

He then presents with bowel obstructionHe then presents with bowel obstruction He is treated medically for obstruction with no He is treated medically for obstruction with no

improvementimprovement A diverting colostomy is performed.A diverting colostomy is performed.

Case 4Case 4

25 y/o male with cystic fibrosis25 y/o male with cystic fibrosis Drug addict (? Dealer)Drug addict (? Dealer) Continues to smokeContinues to smoke Pulmonologist notes that he has missed many Pulmonologist notes that he has missed many

appointmentsappointments PFT’s have been going downhill over past 6 PFT’s have been going downhill over past 6

mos.mos. Fortunately, primary pulmonologist has Fortunately, primary pulmonologist has

discussed code status with this patient.discussed code status with this patient.

Case 4Case 4

He has decided to be a no codeHe has decided to be a no code He becomes more sob and is put on BIPAP for He becomes more sob and is put on BIPAP for

comfort in ICU.comfort in ICU. Morphine dripMorphine drip

Case 5Case 5

80 y/o male with long history CHF80 y/o male with long history CHF Has been hospitalized 3 times in last 3 months Has been hospitalized 3 times in last 3 months

for sob, fluid overload.for sob, fluid overload. Required furosemide drip, oxygenRequired furosemide drip, oxygen ECHO reveals LVEF of 15%ECHO reveals LVEF of 15% He can barely sit upHe can barely sit up He tells you he is ready to die.He tells you he is ready to die.

offering hope to the patient with end stage disease jason corbeill pa-c

Documents

bad newssome patients

steroidscomfort measures

previous patients

bad newsprognosticatingask

bad newsthey

bad newstell

bad newswhen

lung metastases patients