Background: Optimal pain management in the palliative care setting often requires multiple pharmacological interventions including novel and off-label therapies. Ketamine is an anesthetic agent with increasing evidence supporting its use for pain. Through N-methyl-d-aspartate antagonism and activity at opioid receptors, it is an adjuvant to traditional analgesics with the benefit of being opioid sparing. Ketamine has a wide safety profile with limited reports of overdose. Little is published on supratherpeutic dosing in the pain setting.
Objective: We report a case of a 41-year-old male with refractory nociceptive and neuropathic cancer-related pain. Conventional therapies were ineffective. Ketamine was initiated to reduce opioid burden and attenuate pain with good response. The patient received an iatrogenic overdose (10 times ordered dose) of the drug. Several self-limited physiologic and psychologic reactions were observed during subsequent monitoring.
Design: This is a study and analysis of a patient with refractory nociceptive and neuropathic pain syndrome treated with ketamine who sustained an iatrogenic overdose of ketamine.
Conclusions: Ketamine's use to treat pain is increasing along with its evidence of efficacy. Despite ketamine's wide safety profile, the medication is not without risk, especially in palliative care wherein patients are on multiple drugs with potentially severe interactions. Careful examination of the risks of overdose, especially of the various formulations of the drug, is needed.
Opioid addiction, if not well diagnosed and treated, can be a significant challenge for optimal pain management even in cancer patients. To date there is no definitive pharmacological standard of care for treating addiction, especially in this setting of patients. We present a clinical case series of three opioid-addicted advanced cancer patients, effectively treated with haloperidol, a well-known first-generation typical antipsychotic.
Background: Uncontrolled cancer pain is a significant problem in palliative medicine. Opioids are often first-line treatment that increase risks of analgesic tolerance and hyperalgesia. Topical ketamine with other adjuvant pain medications is an often-overlooked treatment, yet may be most effective in difficult-to-treat cancer pain.
Objective: We report a case series of hospice patients with uncontrolled cancer pain who were suboptimally treated with opioids and nerve blocks, whose symptoms responded to topical ketamine with other adjuvants. We review the pronociceptive properties of opioids and how topical multimodal treatment of cancer pain can be more effective than standard opioids, other topical adjuvant medications, and nerve blocks. We discuss the shortcomings of the World Health Organization (WHO) stepladder for the treatment of cancer pain and suggest an adjuvant treatment algorithm, directing physicians to appropriate adjuvant pain agents based on pain type and distinct receptor actions.
Design: This is a retrospective case series of patients who responded to topical multimodal pain treatment with implementation of findings into an addendum to the WHO stepladder.
Subjects: Subjects were from a case series of community-based hospice patients with previously uncontrolled cancer pain.
Measurement: Measurement was made by self-report of pain levels using the 10-point numeric pain rating scale.
Results: Patients' pain was controlled with topical adjuvant medications with return to previously lost function and prevention of otherwise escalating opioid dosing.
Conclusions: These patient cases reveal how ketamine-based topical treatment for cancer pain can be more effective than standard opioids, other topical adjuvant medications, and nerve blocks with no noted side effects and observed reduction in opioid consumption.
Background: Although decongestive physiotherapy combined with diuretics may be efficient in limb edemas, no such therapy has been described in the context of anasarca.
Case Description: A bedbound 62-year-old man with stage IV pancreatic cancer, presenting with progressing severe dyspnea at rest and anasarca, was admitted to the free-standing hospice 3 weeks after receiving nab-paclitaxel with gemcitabine. Two weeks before admission, oral loop and potassium-sparing diuretics were started for bilateral lower limb edema, which progressed to anasarca even though the drug dose was increased. Hypotension hindered further dose escalation of diuretics. Supportive multicomponent bandage compression on both legs with concurrent intravenous furosemide in hypersaline infusion was implemented with good clinical toleration. Afterward, the loop diuretic dose was increased, and supplemented with dexamethasone. A spectacular edema decrease and marked dyspnea improvement with 19 kg body weight reduction were observed within 7 days. Furosemide was switched to oral route and the patient was discharged needing only occasional assistance in daily living.
Conclusion: Compression bandaging with diuretic therapy may be considered even in advanced generalized edemas; however, further studies are needed to determine the adequate therapeutic regime.
BACKGROUND: Depressive disorders are common among cancer patients. Ketamine can quickly relieve depression, and its subcutaneous administration appears to be as effective as and probably safer than its standard intravenous administration. Herein, we report a case verifying the antidepressant effect of a subcutaneous esketamine formulation.
CASE PRESENTATION: A 65-year-old male with metastatic abdominal tumor reported sadness, weight loss, fatigue, hopelessness, insomnia, inattention, and reduced motivation. His scores on the visual analogical scale for pain and Montgomery-Asberg depression rating scale were 8/10 and 30/60, respectively.
POSSIBLE COURSES OF ACTION: Monoaminergic antidepressants are effective, but their response is slow for end-of-life care.
FORMULATION OF A PLAN: Esketamine was preferred because it possibly contributes to pain relief. It can repeatedly be infused intravenously, but was subcutaneously administered twice a week for safety reasons.
OUTCOME: The patient showed continuous mood improvement, achieving depression remission on day 7. Pain relief was observed but without stability. His vital signs remained stable, and he remained calm, without major complaints.
LESSONS FROM THE CASE: Repeated subcutaneous esketamine injections are possibly safe and effective in pain and depression relief in palliative care cancer patients.
VIEW ON RESEARCH PROBLEMS, OBJECTIVES, OR QUESTIONS GENERATED BY THE CASE: Placebo-controlled studies with similar cases are needed to establish efficacy and safety.
At 35, Mr. J. was dying of an invasive pelvic sarcoma and had a tolerance to opioids. Despite his pain, he wanted to be present with his family and friends. When his physician broached the possibility of palliative sedation, he said, “We aren’t there yet.”
The use of long-term and continuous intravenous inotropic support (CIIS) has increased over the past decade. Published evidence indicates that CIIS improves New York Heart Association functional class but does not impact survival. American College of Cardiology/American Heart Association (ACC/AHA) guidelines published in 2013 delineated indications for intravenous inotropic support. Long-term CIIS as palliative therapy (i.e., aim is symptomatic improvement in patients who are not appropriate for surgical therapies) in patients with ACC/AHA Stage D congestive heart failure (CHF) despite optimal medical treatment and device therapy was assigned a Class IIb recommendation (Level of Evidence B).
BACKGROUND: The significance of palliative care consultation in psychiatry is unclear.
ACTUAL CASE SERIES: Analysis of the introduction of palliative care consultation in a large psychiatric hospital.
POSSIBLE COURSES OF ACTION: Continue without offering, survey the need for or offer palliative care consultation, and analyse its introduction.
FORMULATION OF A PLAN: Palliative care consultation was established and details including patient age, department, diagnosis, main problem, solution and discharge were analysed during the first 2 years.
OUTCOME: Two consultations in the first year and 18 consultations in the second year were requested (18 geriatric, 2 addiction, 0 general, clinical social and forensic psychiatry) involving two domains: delirium associated with dementia or another condition (75%) and mental illness (e.g. alcoholic psycho-syndrome, psychosis, suicidal tendency, schizophrenia, depression) and cancer (25%). Recommendations of consultations were realized in 95%.
LESSONS FROM THE CASE SERIES: Implementation of palliative care consultation in psychiatry is one possible method of how to introduce palliative care in a field of medicine with lack of palliative care.
VIEW: Future research should focus on reasons for reservations about palliative care in psychiatry, include more patients with severe persistent mental illness and assess the value of palliative care consultation in resolving this problem.
A 72-year-old man was admitted to the hospital with fatigue. Colonoscopy revealed a 50 × 50 mm rectal tumor with bleeding. Based on close inspection, he was diagnosed with unresectable advanced rectal cancer with multiple liver metastases. Chemotherapy was administered as 10 cycles of bevacizumab + mFOLFOX6 and 7 cycles of bevacizumab + FOLFIRI. Nine months later, he presented with hematochezia and progression of anemia. It was difficult to stop the bleeding via endoscopy. He underwent radiation therapy (39 Gy in 13 fractions), and hemostasis was confirmed. Then, further chemotherapy was performed with 3 cycles of bevacizumab + FOLFIRI and 2 cycles of TAS102. However 14 months after the initial visit, he presented with right hypochondralgia and abdominal fullness due to the progression of multiple liver metastases. Palliative low-dose whole-liver radiation therapy (WLRT) (30 Gy in 10 fractions) was performed. He developed Grade 2 nausea, but his right hypochondralgia reduced, liver dysfunction improved, and he successfully completed radiotherapy. At approximately the same time his anemia progressed, and colonoscopy revealed recurrent bleeding from the tumor. Re-irradiation (15 Gy in 5 fractions) of the rectal tumor was carried out and a blood transfusion was performed for the bleeding. He was discharged after confirmation the anemia had not progressed. Few reports have been published on the use of both palliative re-irradiation to stop bleeding from rectal cancer and palliative low-dose WLRT. Based on our experience with this case, we believe that palliative radiotherapy can be useful in treating patients with a poor prognosis.
INTRODUCTION: Palliative care (PC) aims to treat symptoms independently of the disease. In many medical disciplines, including oncology, there is an emphasis on personalizing treatment, identifying the most effective therapeutic option by studying the genetic heritage of the patient and the molecular characteristics of the disease. PC, on the other hand, encompasses the overall (physical and spiritual) well-being of the patient and his or her caregivers. The increasing use of early PC and its integration with oncology could represent a fruitful collaboration among specialists.
CASE DESCRIPTION: We present the case of a 79-year-old woman with advanced breast cancer attending our institute who was referred to our PC Unit because of continuous ear pain, paresthesia around the mouth, strabismus, and facial dysesthesia. The patient was in good clinical condition (Eastern Cooperative Oncology Group 1) and was undergoing chemotherapy at the time. For these reasons, the PC physician carefully assessed the pain characteristics and differential diagnosis and discussed them with the oncologist, radiologist, and neurologist. Joint consultation led to a specific study of Meckel cave by MRI, revealing an extrameningeal gasserian ganglion metastasis, a very rare localization of breast cancer.
CONCLUSION: We present a case that underlines the importance of specialized PC assessment not limited to the control of symptoms. The search for the etiopathogenesis of a patient's symptoms and the evaluation of overall clinical conditions may be necessary to plan appropriate diagnostic evaluations, target palliative therapies, and achieve effective symptom control.
Surrogate health care decision making is often a challenge for everyone involved. In the case of incapacitated patients, family members, nurses, health care providers, and other members of the health care team often grapple with determining the most appropriate clinical course of action. For these difficult patient scenarios, the expertise of clinical ethics consultants is sought to assist with complex health care decision making. Clinical ethics consultation is designed to provide a more objective “outside” opinion and offer advice to the patient, family, and entire care team to support and guide decisions. Nurses are well positioned to initiate assistance from Clinical Ethics Consult Services in support of patient and family advocacy. This article presents a case analysis based on the Stakeholder, Facts, Norms, and Options Framework to analyze the best interest course of action for Mr K., a patient diagnosed with abdominal pain due to end-stage liver cirrhosis and who lacks decisional capacity in regard to his own treatment decision making. The case analysis highlights specific examples of how nurses can provide information, facilitate discussion, and otherwise support patients and families to achieve best interest outcomes.
Cet ouvrage est le journal de bord d'une mère de 32 ans atteinte d'un cancer. Les entrées, qui s'étalent d'octobre 2017 à septembre 2018, relatent les bons et les mauvais jours ainsi que les réflexions de l'auteure sur l'impact familial, financier et social de la maladie.
Background: End-of-life dreams and visions (ELDVs) are a recognized phenomenon that can occur as part of the normal dying process. Data suggest that ELDVs can provide comfort, foster discussion of waking life concerns, and lessen the fear of death. Current literature on ELDVs focuses on the prevalence, content, and effects of ELDVs exclusively in adult populations.
Methods: We present the case of a 15-year-old girl with terminal glioblastoma who was enrolled in a pediatric palliative care program and later in hospice care. During her end-of-life trajectory, the patient experienced two distinct ELDV experiences, from which she recalled vivid details regarding the setting, characters, and content. These ELDV experiences afforded comfort and meaning to the patient and her family through her end-of-life trajectory as well as provided relief for her grieving family.
Conclusion: In the case presented, ELDVs appear to show similar characteristics and impact in the adolescent population as described in the previous literature examining adult ELDVs. In addition, this case demonstrates the potential benefits of ELDV awareness for the bereaved. Clinicians working with pediatric and adolescent end-of-life populations should take note of the potential for ELDVs and the impact they can have on both patients and families.
OBJECTIVE: This case report presents an unusual case of clozapine toxicity secondary to reduced smoking habit mimicking a patient approaching end of life.
METHODS: It is a cautionary tale for palliative care specialists, perhaps unaware of the effect of cigarette smoke on metabolism of this antipsychotic, to be aware of.
RESULTS: Following specialist advice and change of antipsychotic medication, this patient's condition improved to the point that he was discharged from the hospice.
CONCLUSION: Palliative care specialists should be aware that reducing cigarette consumption can alter metabolism of clozapine, potentially causing drug accumulation and toxicity with features which mimic deterioration towards end of life. Specialist advice should be sought in such a situation.
Hepatocellular carcinoma (HCC) with right atrial (RA) tumor thrombus via progression through hepatic veins into the inferior vena cava is a challenging entity with limited treatment options. We describe a case of a patient with a symptomatic HCC RA tumor thrombus who achieved a durable and effective symptomatic response to palliative radiotherapy. We also report our institution’s experience treating 10 HCC patients with RA tumor thrombus with palliative radiotherapy to a median biological effective dose (a/ß = 10) of 50.6 Gy (range, 29.3-71.2 Gy). Median follow-up was 5 months. Palliative radiotherapy was well-tolerated, with no grade = 3 acute toxicities. Only one patient experienced in-field progression. Seven patients were alive at least 3 months following radiotherapy, and median overall survival was 5 months (range, 3-15 months). This unique series suggests HCC RA tumor thrombus-directed radiotherapy may offer safe palliation and can be considered to improve patients’ quality of life.
Many patients with advanced, non-curable cancer experience disease progression to a stage requiring symptomatic care alone. The integration of palliative care into oncology practice is therefore important, with many studies showing the benefits of early introduction of palliative care. In addition to symptom relief, palliative care can include psychological, social, and spiritual support. Although all oncologists provide basic palliative care, recent data indicate that the parallel involvement of a specialist palliative team that addresses the psychological, social, and spiritual needs of patients may be advantageous for both patients and their families. This mode of early integration of palliative care has been found to enhance patient quality of life and to provide more effective use of costly treatments. In Czech hospitals, however, this mode is rarely employed. Palliative care is usually perceived as an end-stage approach, which is initiated only when all other anticancer treatment modalities have been exhausted. This case describes the challenges and missed opportunities when palliative care was initiated late during the dying phase of a young female patient with metastatic colorectal cancer, and it discusses the potential benefits of early integration of palliative care. Supported by Ministry of Health of the Czech Republic, grant No. 15-33590A.
Introduction: La nutrition artificielle en fin de vie est un sujet complexe. Elle amène souvent de nombreux questionnements, car elle est liée à de nombreux symboles se rapportant à la société, l’éthique, les soins et bien d’autres.
Matériel et méthode: Il s’agit d’une étude de cas autour d’une situation complexe de nutrition artificielle chez un adulte atteint de trisomie 21 dans un contexte palliatif.
Résultats: La décision d’entreprendre ou non une nutrition artificielle ne relève pas, dans ces situations complexes, d’une certitude médicale. Tous les acteurs soignants et non soignants de la prise en charge doivent alors interagir de façon à définir la solution la moins délétère pour le patient, car très souvent il existe des arguments pour et contre la nutrition. La souffrance et les représentations des proches sont également des éléments impératifs à prendre en compte et un accompagnement tout au long du processus décisionnel doit être réalisé.
Conclusion: La décision finale de nutrition artificielle en situation complexe doit être prise au terme d’une réflexion incluant tous les acteurs médicaux et non médicaux. Cette décision doit être expliquée à tous et un accompagnement adapté doit ensuite être proposé au patient et à ses proches ainsi qu’une réévaluation régulière des soins et du confort.
The ethics of perinatal care, and the experiences of families who receive such care, remains a nascent area of inquiry. It can be hard to see how existing "good death" constructs apply to the experiences of fetal patients and their families. In this paper, we explore two themes raised by a case at our fetal health center: anticipation and accompaniment. In this case, a mother presented to our fetal health center; her unborn son, our fetal patient, was diagnosed with life-threatening hypoplastic left heart syndrome and endocardial fibroelastosis. The parents were told that their son's life expectancy, upon birth, was short. For us, this case raised important questions around what sorts of things we might, together with the family, anticipate with respect to their son's birth and death, and what it meant to really accompany this family on their journey. Alongside conventional lessons in the philosophical literature and palliative care practice, the process of anticipating together and of mutual accompaniment helped us to guide this family to what they ultimately determined to be a good death for their son.
Background: Clinicians at the bedside regularly encounter surprises or unexpected clinical developments that carry emotional, social, or moral overtones-especially when death is anticipated or when patients are particularly vulnerable. In such circumstances, clinicians may struggle to find practical clarity in making treatment plans that honor their fiduciary (literally, "entrusted") duty to uphold equitably the ethical principles of beneficence, nonmaleficence, patient autonomy, and justice.
Methods: We present the case of a patient who appeared to be actively dying and received an indwelling urinary catheter for the purpose of ensuring comfort. However, it led to an unintended reversal of renal failure and exacerbation of underlying psychiatric disease. This led to a meaningful change in the patient's prognosis. It also created pragmatic challenges to shared decision making, which required an intentional interdisciplinary approach to balancing beneficence and patient autonomy. Conclusion: Palliative Care offers a holistic clinical approach to complex suffering. Palliative care specialists develop advanced skill sets in prognosis estimation, nuanced communication issues, and patient-centered goal setting. As this case highlights, prognosis can shift dramatically in the perimortem period, even with small changes in care plans. This case presented several biomedical, social-cultural, and ethical challenges to the team. Lessons from the case are presented regarding: the role a specialist palliative team might play throughout all stages of serious illness; approaching prognostication as an iterative rather than solitary task; and utilizing an ethical framework to care planning when there are barriers to shared decision making.
Diphenhydramine (DPH) is an over-the-counter antihistamine medication commonly used for symptom management in palliative care. Despite the ease of access and perceived safety of DPH, there is documented evidence of potential for abuse of this medication. We present a case of a 61-year-old man with metastatic carcinoma of the distal esophagus, who was initially admitted with a pain crisis but subsequently developed a severe DPH withdrawal syndrome consisting of hyperactive delirium, autonomic dysfunction, and increased muscle tone. With careful selection of the antipsychotic agent loxapine, additional symptom management medications and scheduled tapering the patient was able to be discharged home for end-of-life care. We highlight the challenges of recognizing and managing a withdrawal syndrome in patients with terminal illnesses at end of life.