Your Next Patient: A 62 Year Old Man With Advanced Lung Cancer

It’s 9PM in your busy emergency department when an ambulance arrives with a 62 year old man who appears to be very short of breath. His wife explains that he has advanced metastatic lung cancer and has been waiting for a bed at a local hospice, but none have been available. They have been trying to manage at home but he has been getting worse rapidly today. Tonight he is struggling to breathe and in pain. He has been unable to take his medications because of breathlessness so they called the ambulance.

You review the patients records and find that he is a long-time smoker and has COPD. About one year ago he developed lung cancer. It was metastatic at the time of discovery and unresponsive to chemotherapy. Currently the cancer is widely metastatic in both lungs with invasion into the left chest wall causing severe pain. The patient has been followed by palliative care and has a do not resuscitate order in place.

On examination the patient is a cachetic man in overt respiratory distress and moaning in pain. His vital signs are: HR 120, RR 30 (shallow/laboured), BP 100/60, O2 80% on room air. Examination reveals the following positive findings: bilateral firm fixed supraclavicular adenopathy, no audible air entry on the left lung field with dull percussion tone, poor air entry on the right lung field, with a palpable right lateral chest wall mass. Heart sounds are noted to be tachycardic and diminished and jugular venous distension is present. Abdominal examination reveals an enlarged hard liver edge, suspicious for metastatic disease.

The patient has respiratory distress, diminished heart sounds and JVD. This raises a number of diagnostic possibilities familiar to most emergency physicians. In our patient, with advanced cancer, there are some additional important considerations.

  • Pericardial tamponade
  • Tension pneumothorax
  • Massive pulmonary embolism
  • Superior vena cava syndrome
  • Tension hydrothorax
  • Lobar collapse/lobar atelectasis
  • A complex combination of more than one of these possibilities

This is a complex question. A do not resuscitate order in it’s most basic form is only useful when the patient arrests and it does not provide any other guidance for the patients medical care. The presence of a do not resuscitate order may allow the physician to focus on treatment goals that have short term positive benefits.

Some patients may have detailed advanced directives that spell out the patients wishes in specific circumstances but this is rare. In the case of our patient he has a signed and witnessed document that states ‘In the event of death please do not resuscitate, please allow a natural death.’

It is also important to note that a DNR order can be revoked or changed at any time by the patient.

Like all other care decisions the physician must discuss options with the patient. In this case the patient is experiencing an uncomfortable natural death and available options aimed at relieving that suffering should be offered.

Our patient has severe dyspnea and pain due to tumor invasion of the chest wall. He has been unable to take his medications due to breathlessness.

The cornerstone of initial management is parentral opioids. In this case an opioid medication will provide both pain relief and relief of dyspnea. Either intravenous or subcutaneous medication is acceptable and medication should be titrated to symptom relief. Medications with a long interval to onset of action, such as transdermal fentanyl patches, should be avoided for acute symptom management.

Severe dyspnea can cause anxiety in many patients. In some patients anxiety resolves as the symptoms are controlled, while others require specific treatment with benzodiazipines.

Our patient receives hydromorphone 0.5mg IV q5minutes x 3 doses (1.5mg total) and has good relief of both his pain and dyspnea. His anxiety is also greatly reduced and he is offered lorazepam 0.5mg sublingual but he declines.

The doctrine of double effect (DDE) is a philosophical principle (probably first discussed by Thomas Aquinas). The principle is that harms are sometimes a side effect of actions intended to bring about a good result, and that these unintentional harms are ethically permissable.

In our case the doctrine of double effect is important. Some physicians are reluctant to treat palliative patients with opioids or benzodiazipines for fear they will hasten their death. This doctrine permits the treatment of palliative patients pain and suffering, even if that same treatment also hastens their death.

(In fact proper pain treatment has never been shown to hasten death, but this myth persists and is worth addressing.)

Our patient initially decides he might consider interventions that would improve his symptoms and some investigations are undertaken. A bedside ultrasound shows a moderate sized pericardial effusion. A CT scan shows diffuse metastatic lung cancer with a high disease burden, there is a massive left effusion with some mediastinal compression and diffuse liver metastases are now apparent. The patient is anemic with a hemoglobin of 71, and has metabolic derangement with a creatinine of 425, BUN 25 and K 6.0.

You discuss the results with the patient and offer interventions likely to improve symptoms, in particular left thoracocentesis. You discuss the difficulty of managing severe anemia and hyperkalemia in the face of renal failure. The patient decides that he does not wish to have any interventions except medications for pain control as he has had good results with the IV hydromorphone. You admit him to the hospital to wait for a bed in hospice but the hospital is over full so he remains in your emergency department.

Four hours later you are approached by the patients wife. She tells you that the patient is deeply sleeping with shallow and slow respirations. She is concerned because he has a loud gurgle in his throat and wonders if there is anything that can be done about this?

  • Glycopyrolate 0.1-0.2mg SC q2-4h
  • Scopolamine 0.3-0.6mg SC q3-6h
  • Atropine 0.1-0.4mg SC q2-4h

The patient is treated with glycopyrolate with good result. He dies 2 hours later still in our emergency department having never been admitted to a hospital bed or hospice due to overcrowding.

Palliative care seems on face as far out of the realm of emergency medicine as can be. However, with chronic overcrowding, hospital and hospice congestion and boarded patients a fact of life in most emergency departments, means that the provision of palliative care is becoming an important consideration for many of us.

Facing the Inevitable

There is a very nice reflection today on Kevin MD about Atul Gawande’s recent article about surgical care near the end of life. The crux of the argument is that it’s complicated, and that it’s poorly done.

In the emergency room we see people for such a brief snippet of their life, and we can rarely place an acute severe illness in the context of that patient’s existence. A patient with severe pulmonary edema doesn’t come through the door with the context of healthy, vibrant and functional, or debilitated, frustrated, and dependent readily apparent. There is no access to old charts, or family doctors or family members in the initial minutes where this patient will live or die. Sometimes the only context we have is the context of the moment. The patient’s context is also severely limited. They fully understand the context of their life, but often don’t appreciate the cascade of events that can flow from these initial decisions. I think it is very difficult to pass judgement on doctors or patients who live in these moments and make the decisions they think are best with very limited information.

We live lives of discrete events and achievements, and we don’t always appreciate the movement in between these moments. Skydiving; check, tattoo; check, backpack across Europe; check, bachelor party in Vegas; check; Married/kids/house/car; check; Blown out knee; check, MI; check… You get the idea, but does a 90 year old patient with dementia, from a nursing home, with cough, fever and an infiltrate on chest x-ray really have pneumonia, or do they have progressive dementia evidenced by pneumonia? The difference is important, the first is a check box and if the patient survives it is a discrete event and part of the past, while the second describes a moment within a greater movement.

As emergency physicians we must do what we do within the limitations of the available information; but this does not absolve us of our responsibility. When we overstep we must be prepared to backtrack, sometimes to remove interventions we have already made. We must try to understand the patient’s context when we can, and place the current events into that context. As a society, as families, and as physicians we need to consider the overall context of things, the greater movement of life, and how the interventions we choose or do not choose will shake out in the longer term. We (society, patients and physicians) will all be called upon to do better when faced with the inevitable.