By: Karen Cousins-Brown, D.O., CMD
A 61-year-old male – homeless, but social and productive in his community – has a diagnosis of advanced non-small cell lung cancer, failure to thrive, near obstruction due to superior vena cava syndrome, debility, and a right-sided non-malignant pleural effusion. Despite receiving chemotherapy with Cisplatin and radiation, he continued to decline. He decided to discontinue treatments and signed onto hospice. Upon hospice admission from a local hospital, he was taking MS Contin 30 mg every eight hours and Oxycodone 10 mg every four hours PRN for pain. He became progressively bedbound, ate a minimal amount, exhibited depression and presented with significant, variable pain management issues. What treatment options are available for this patient?
Hospice and palliative care medicine focus on improving the quality of one’s life rather than on curative medical options, and expert pain and symptom management are a large part of achieving quality of life objectives. Statistics show that, while cancer pain can be managed well in 90% of patients, it often is not. Pain management can be challenging, yet can be tackled successfully with a thorough assessment of cancer pain, non-cancer pain and non-physical types of pain.
First, the hospice team assessed the cancer pain. Cancer pain can be bony, neuropathic, visceral or intramuscular. The patient had a dull ache in his shoulders, legs and back that increased with ambulation and weight-bearing. For the bony pain, the patient was already on an opioid that, while progressively increased to Morphine 75 mg twice daily, was still ineffective. In this case, an NSAID, steroid or both can be used. We started him on Decadron 4 mg twice daily. Within a few days of starting the steroid, the patient was able to ambulate again, increase his food intake, and generally function better.
His non-cancer pain (arthritis, headaches and constipation) also was assessed. The patient did have occasional headaches that resolved with the steroid. An NSAID could have been used in lieu of the steroid. For many hospice patients, non-physical pain, including feelings of anxiety, denial, fear, and hopelessness, can be even more important to treat than their physical pain. The hospice team — including the physician, nurse, social worker, clergy, volunteer coordinator and multiple volunteers — saw the patient and addressed his fear of aloneness, loss of independence and denial of his medical condition. Other patients in the hospice facility befriended him, sharing time and conversation outside on a wooden deck adorned with beds of planted flowers. These types of emotional and spiritual support, tailored to the patient’s needs, are important components of hospice care that are specifically mandated by federal regulations.
The patient is now ambulatory, eats regularly, goes out independently at times with friends and still performs odd jobs, all of which bring him pride, self worth, and a feeling of purposeful living. This patient’s case exemplifies how a hospice team approach can effectively address myriad types of pain and dramatically improve the physical and emotional lives of terminally ill patients. He is also a testament to one of the core precepts of hospice, namely giving patients the right to die without pain and with dignity.
As long as this patient lives, he will receive compassionate care directed at expert management of his pain, symptoms and a high quality end-of-life.
Hospice is now a significant player in end-of-life care options and statistics demonstrate its appeal. The latest usage data, compiled for 2009 by the National Hospice and Palliative Care Organization (NHPCO), shows hospice as a steadily growing resource for the terminally ill, with an estimated 41.6% of all U.S. deaths occurring under hospice home care or inpatient services. More than 5,000 hospice providers in the country now meet this steadily growing demand, providing an average 69-day service per patient. According to the NHPCO, cancer diagnoses account for 40.1% of all hospice admissions, followed by debility unspecified (13.1%), heart disease (11.5%), dementia (11.2%), and lung disease (8.2%).
Karen Cousins-Brown, D.O., CMD, earned her Doctor of Osteopathy from the Philadelphia College of Osteopathic Medicine. She is the Medical Director at Maryland General Hospital in Baltimore, Maryland of the Acute Care Unit for the Elderly and is the Clinical Preceptor for the Johns Hopkins Geriatric Fellows for the Unit. In addition, Dr. Cousins-Brown is the Medical Director for Joseph Richey Hospice in Baltimore and serves as Long Care Attending for several nursing facilities in the greater Baltimore Metropolitan Area. She can be reached at email@example.com.