Background: This case report describes a patient with known idiopathic Parkinson’s disease, being managed with transdermal rotigotine, whose refractory nausea and vomiting was successfully controlled with subcutaneous levomepromazine. No drug-induced extrapyramidal side effects emerged.
Case presentation: A patient was found to have a locally advanced serous carcinoma, causing secondary bowel obstruction. Furthermore, due to compromised oral access, the patient’s oral antiparkinsonian medications for motor control were converted to transdermal rotigotine. Unfortunately, the patient’s nausea and vomiting was refractory to a number of recommended antiemetic options.
Case management: Low dose levomepromazine was administered on a, ‘when required’ basis, via subcutaneous injection.
Case outcome: After the first dose of levomepromazine, the patient’s nausea and vomiting completely subsided and no extrapyramidal side effects were observed. This was confirmed by daily assessments, revealing no worsening of the motor symptoms associated with idiopathic Parkinson’s disease.
Conclusions: The pharmacology of rotigotine and levomepromazine appear complementary and may allow for the simultaneous use of both drugs, with favourable outcomes. This case report highlights that rotigotine may afford protection against antipsychotic induced extrapyramidal side effects, while preserving antiemetic effects. Such combinations may have a role in the end-of-life management of idiopathic Parkinson’s disease.
Advanced heart failure therapies such as ventricular assist devices and home inotrope use are becoming more common. Technology advances as well as increased indications for use of such therapies is leading to a higher percentage of patients with end-stage heart failure receiving these therapies at end of life. We present a case of a young man with dilated cardiomyopathy who undergoes advanced cardiac care in the setting of progressively declining cardiac function. Our case outlines the importance of acute care, palliative care, and hospice services being coordinated prior to and during acute-care services to provide goal-concordant and expeditious care. With advancing medical therapies for heart disease, increased coordination and collaboration of services are needed, particularly between hospice and acute-care services.
With various serious illness, patients experience high levels of functional loss, deconditioning, and dependency for activities of daily living (ADLs). This can lead to social isolation, depression, caregiver breakdown, and institutionalization. This fast fact wil review the benefits and challenges of palliative rehabilitation.
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Hypercalcemia of malignancy affects 2%-2.8% of cancer patients and is associated with an increased risk of mortality and other symptom-related complications. Standard treatment consists of fluid resuscitation, intravenous bisphosphonates, and calcitonin. Little is known, however, about the benefits of treatment of malignant hypercalcemia in patients with late-stage terminal cancer. We present a case of a hospice patient with squamous cell lung cancer brought to our hospital with newly altered mental status who was found to have hypercalcemia of malignancy. Our discussion centers on the diagnostic dilemma of deciding which patients seeking comfort-focused care may benefit from fluid resuscitation for symptoms of hypercalcemia of malignancy while maintaining the unambiguous goal of comfort care.
RATIONALE: Syncope caused by head and neck cancer (HNC) is rare. However, syncope caused by tongue cancer (TC) is even rarer. In TC, syncope is caused by tumor-mediated compression of the carotid sinus and stimulation of the glossopharyngeal nerve.
PATIENT CONCERNS: In this study, we report the case of a 48-year-old male patient who was diagnosed with advanced TC and bilateral cervical lymph node metastasis. On the third day of admission, the patient experienced recurrent syncope with hypotension and bradycardia.
DIAGNOSES: The patient was diagnosed with a well-differentiated squamous cell carcinoma of the tongue along with massive cervical lymph node metastasis and carotid sinus syndrome.
INTERVENTIONS: Initially, symptomatic treatment of syncope boosted the blood pressure and increased the heart rate. Thereafter, a temporary pacemaker was implanted. Finally, chemotherapy was used to control the tumor and relieve syncope.
OUTCOMES: After chemotherapy, the tongue ulcers and cervical lymph node reduced in size; syncope did not recur.
LESSONS: This case shows that chemotherapy may be a valid treatment option in patients with cancer-related syncope; however, the choice of chemotherapeutic drugs is critical. Intensive care provides life support to patients and creates opportunities for further treatment.
Checkpoint immunotherapy is a rapidly evolving treatment paradigm for solid organ cancers. These medications are often antibodies that target key regulators of the immune system to unleash an immune system attack on cancer cells. Examples include cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitors (e.g., ipilimumab) or programmed death receptor-1 (PD-1) inhibitors (e.g., pembrolizumab and nivolumab). See Fast Fact #277 for more information. Although heightened immune response against the tumor cells is intended, healthy tissues can also be attacked leading to unintended inflammation of almost any organ system. This has led to a unique set of immune-related adverse events (IRAEs). Given the expanding use of checkpoint immunotherapy, clinical awareness of IRAEs is important among generalist and palliative care clinicians.
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Background: Abrupt withdrawal of pharmacological therapies for myasthenia gravis can exacerbate muscle weakness and even trigger myasthenic crisis. Such medications should ideally be continued, but how this can be achieved in patients approaching the end of life, particularly when enteral administration is compromised, has not been defined.
Case History: An 83-year-old man with a history of generalized myasthenia gravis and palliative metastatic anal adenocarcinoma was admitted to his local hospital with general decline, where he was considered by more than one physician to be actively dying from his cancer. In the days preceding admission, the patient had not taken his medications consistently, including the acetylcholinesterase inhibitor, pyridostigmine, for the management of his myasthenia gravis.
Case Management and Outcome: Reintroduction of the patient's usual myasthenia therapy improved his clinical condition to the point where he was no longer thought to be dying. When enteral administration of pyridostigmine was no longer possible, the patient was successfully converted to neostigmine, which was administered as a continuous subcutaneous infusion.
Conclusion:Undertreated myasthenia gravis can lead to a rapid deterioration in a patient's clinical condition, and such patients may be mistakenly diagnosed as dying. Undertreated myasthenia gravis should therefore be considered as a potentially reversible cause of acute deterioration, especially in patients with complex comorbidities. The use of neostigmine as a continuous subcutaneous infusion may have a role in the management of such patients, particularly when enteral administration of acetylcholinesterase inhibitors is no longer possible.
OBJECTIVE: Major depressive disorder (MDD) is common in patients diagnosed with advanced cancer (AC), with a prevalence of 16.5%. It is associated with great disability and worsened quality of life, increased number and intensity of physical symptoms, and lower survival. It is the main factor for the presence of suicidal ideation. Antidepressants show modest efficacy, and response requires several weeks. Ketamine has demonstrated a fast and robust antidepressant effect in subanesthetic doses. This effect may prove useful in patients with AC, MDD, and suicidal risk.
METHOD: We report a case of a patient with advanced cervical cancer who presented with uncontrollable pain, MDD, and a suicide attempt.
RESULT: A 39-year-old woman diagnosed with cervical cancer stage IVB presented to the Emergency Department after a suicide attempt by hanging. Upon evaluation by the palliative care psychiatrist, she reported intense pain, unresponsive to analgesics, and had a history of persistent suicidal ideation. Antidepressant treatment was started (sertraline 50mg/d) after a single dose of ketamine hydrochloride IV (0.5 mg/kg) was administered. Treatment response was measured using the Brief Edinburgh Depression Scale before and after the intervention. The depressive symptoms decreased by 17% on day 1, 39% on day 3, and 72% on day 17.
SIGNIFICANCE OF RESULTS: This case report shows ketamine's efficacy as an augmentation agent alongside conventional antidepressant treatment in patients with AC. Moreover, it shows rapid response in suicidal ideation that has not been achieved with treatment as usual. More clinical trials are needed to support the potential benefit and safety of ketamine in patients with AC, MDD, and persisting suicidal ideation.
As hospice and palliative care populations shift from the majority having a primary cancer diagnosis to most with a noncancer diagnosis, clinicians are challenged with caring for chronically ill patients with multiple comorbidities. In addition to traditional pain and symptom management, patients’ comfort goals are frequently addressed by managing the underlying disease and comorbid conditions. As a result, many patients have extensive medication profiles. This raises the potential for drug-drug interactions at cytochrome P450 pathways that can interfere with anticipated drug response. Likewise, polypharmacy can be problematic when using palliative care order sets and hospice comfort kits to manage emergent symptoms or as the patient approaches death. This is further complicated when medications are administered before a pharmacist’s review for drug interactions. This article provides an overview of cytochrome P450 and uses an unfolding case study approach to explore interactions that may occur within a patient’s medication profile or in combination with medications commonly used by palliative care and hospice.
Introduction: the concept of total suffering is well known to palliative care, and it indicates that there are several complex and correlated factors, which contribute to a dynamic and unique experience of one's illness trajectory. Research on terminally ill patients' will to live (WtL) has revealed important insights on its fluctuations over time and its correlated factors. We report an N-of-1 case study with the aim of examining the concept of total suffering objectively, and the WtL trajectory over time, its fluctuations, as well as its possible correlation with other distressing symptoms in a terminally ill cancer patient.
Case Description: souffrA 72-year-old cancer patient who verbalized total suffering and a low WtL. We used the Edmonton Symptom Assessment Scale (ESAS), added an additional WtL question, and asked the patient to rate her suffering using the ESAS twice daily (morning and afternoon) for a period of 28 days. Spearman's correlation coefficients between all physical and psychosocial ESAS items were statistical significant in 34 of the 45 performed correlations (30 highly significantly correlations and 4 in a lesser degree). WtL trajectory was fluctuant through the course of the illness, and significant correlations between WtL and all ESAS items were found, except for shortness of breath and drowsiness (after Bonferroni correction). High positive correlations were found between WtL and ESAS total score and ESAS physical and psychological subscores.
Discussion: Developing evidence-based understanding of total suffering and WtL in the terminally ill will lead to better approaches to patients and their loved ones.
Background: Third-degree atrioventricular (AV) block can result in sudden cardiac death if no reliable escape rhythm is present. Here, we report a case of an 86-year-old female patient who developed a third-degree AV block leading to cardiac arrest. Surprisingly, sinus rhythm returned after 4 min of asystole, and she showed complete neurological recovery.
Case summary: Emergency services were contacted by the husband of an 86-year-old woman after she was found unconscious. Ambulance personnel diagnosed a third-degree AV block without an escape rhythm and transcutaneous pacing was started. At arrival on the emergency ward, pacing was inadequate, resulting in absence of circulation for ~10 min. After consultation with the family, the patient turned out to have signed a ‘do not resuscitate’ order. Given the impression that the considerable delay deemed favourable neurological recovery unlikely, it was decided together with the family to stop the resuscitation. Subsequently, she had an intermittent junctional escape rhythm but eventually developed a documented asystole of more than 4 min. Against all expectations, she regained sinus rhythm and fully recovered. Eventually, a pacemaker was implanted and she was discharged home without neurological sequalae of the cardiac arrest.
Discussion: Autoresuscitation, also known as the Lazarus syndrome, is the spontaneous return of circulation after cardiac arrest and is incidentally seen after failed cardiopulmonary resuscitation (CPR). Autoresuscitation in the absence of CPR is highly unusual, but could, in this case, be due to the total AV block as the cause of the cardiac arrest.
The impostor phenomenon (IP) describes the experience of questioning one's abilities and fearing exposure as an intellectual fraud, despite objective evidence of success. The IP has been identified in high-achieving professionals across a variety of disciplines, including clinical medicine, and can be associated with significant anxiety and psychological distress. In this series, we present three authentic cases that demonstrate how the IP may manifest in palliative care practice. Acknowledging the current emphasis on clinician wellness and burnout, we suggest that the IP may be one important source of distress for many early-career clinicians in palliative care. With the physician as the focus of each case, we explore the difficult emotions faced and highlight how palliative care clinicians may be uniquely vulnerable to the IP. We then identify concrete strategies to help clinicians manage feelings of IP and enhance their professional well-being.
OBJECTIVE: The case of a non-oncological patient at the end of his life, admitted to a Palliative Care Unit (PCU), is presented. After a failed attempt to place a central venous catheter (CVC) and another placement of a peripherally inserted central catheter (PICC), the patient exhibited high anxiety regarding a midline catheter (MC) and refused its placement, even though this was necessary for the administration of intravenous drugs to control dyspnea and other complex symptoms that he presented.
METHOD: An intervention through clinical hypnosis for successful MC placement and symptom control is described.
RESULT: Through clinical hypnosis and interdisciplinary teamwork, it was possible to place a MC, necessary for symptomatic control of a complex patient.
SIGNIFICANCE OF RESULT: This case exemplifies hypnosis as a simple procedure that is easy to apply, accepted by the patient, and effective in the implementation of invasive procedures and symptom control in PCUs.
This is an evidence-based case study examining the process and outcome of 22 prenatal sessions and 1 postpartum follow-up session of psychodynamic therapy for a woman pregnant after a history of repeated pregnancy losses. Self-report measures of depression, anxiety, pregnancy-specific anxiety, prenatal attachment, trauma, and perinatal grief were completed prior to each session. A session quality item was completed after each session and a therapy outcome measure at termination and follow-up. The therapist and the patient completed an exit interview on the therapy relationship, which focused on moments of tension or misunderstanding, over the course of treatment. All sessions were transcribed and scored by certified raters for reflective functioning. Results suggest that the patient experienced reliable and clinically significant change on all pregnancy-specific measures, with most change happening in the early phase of treatment. However, general symptoms of depression and anxiety were variable and highly volatile over time. Exit interviews suggest that therapist empathy and validation were helpful in promoting change on pregnancy-specific symptoms, whereas problems or ruptures in the alliance may have been associated with a lack of change on general psychiatric symptoms. The patient showed little change on reflective functioning, perhaps contributing to ruptures in psychotherapy and lack of change on general psychiatric symptoms.
Novel immune-based cancer therapies such as programmed death 1 (PD-1) inhibitors continue to emerge for both curative and palliative intent. Post-market data of PD-1 inhibitors indicate that there are a wide range of side effects associated with these drugs, including ones that have relevance to symptom control and represent a diagnostic challenge at the end of life. We present a case of pembrolizumab-induced hypothyroidism causing extreme fatigue and persistent hypoglycemia.
Opioids have long been a mainstay of symptom management in palliative care (PC), allowing patients with terminal illnesses to have an improved quality of life. Unfortunately, these same medications have contributed to the explosion of the opioid epidemic. This article explores the case of a patient with opioid use disorder (OUD) and pancreatic cancer. We share our experience of managing his symptoms and treating OUD in the setting of an outpatient PC clinic. We explore the challenges and joys of this case while reflecting on the need for more research investigating best practices for individuals where opioids serve as both a pain reliever and contributor to further suffering from their OUD.
BACKGROUND: In the setting of critical illness, life preservation may come at the expense of limb as increasing concentration of vasopressors causes peripheral ischemia. When goals of care specify comfort measures, clinicians are faced with the difficult task of mitigating already present distal malperfusion while abiding to wishes of patient and patients' families. Physical changes post vasopressor use, such as mottling of appendages or cooling of skin, can limit meaningful physical interactions with grieving family members.
CASE PRESENTATION: We describe a case series of successful utilization of intravenous nitroglycerin to improve postvasopressor digital ischemia for comfort care measures to assist patient's families in the grieving process.
CONCLUSION: Following decision for comfort care measures, management for patient care goes beyond the realm of pain control. Dignified dying is an active process that requires clinicians to navigate care for both patient and patients' families. By reversing the digital ischemia associated with vasopressors, patients' families have the opportunity to give meaningful touch in setting of which it may be needed most.
Background: Opioid refractory pain is a common problem in pain management. Dexmedetomidine is suggested to have opioid-sparing effects, with well-described use in surgical and intensive care unit settings. Some authors advocate its benefit in reducing delirium. Its effects are thought to be exhibited through agonism of pre- and postsynpatic a2-receptors in the central nervous system. It is more selective on a2-receptors than clonidine, accounting for its relatively lower incidence of hypotension. Its use in sedation is favored because it does not depress the respiratory system. The main side effects reported include bradycardia.
Case Description: Twenty-eight-year-old woman with triple negative left breast cancer and a locally destructive tumor was admitted to hospice after exhausting her disease-directed therapy options. Her chief complaint was a throbbing, burning pain to the left chest wall, lower back, and bilateral lower extremities, rated 8/10 on a 10-point verbal scale. Multiple pharmacologic agents for pain, including patient-controlled analgesia infusions with adjuvant methadone and steroids, had failed to provide consistent pain management. Symptoms were difficult to control in the home setting, and she required multiple admissions to our inpatient hospice unit for pain management. She also developed episodes of delirium shortly after hospice admission. We attributed her symptoms to rapid disease progression. After failed pain control with opioids, ketamine, and lidocaine, we trialed a dexmedetomidine infusion. While on the infusion, her pain rating decreased to 0/10 and she had no delirium. Pain recurred soon after cessation of the infusion, initially rated 6/10.
Conclusion: Dexmedetomidine is safe for opioid refractory pain in the hospice inpatient setting. However, its effects may not be sustained. There is potential for use in end-of-life care, with added benefit for possible control of delirium.