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End-of-life care: when chemotherapy may not be the best option
One patient's severe hepatic dysfunction limited chemotherapy options.
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A 62-year-old man presented to the emergency room with jaundice, abdominal pain, hypercalcemia and respiratory distress. He had been undergoing outpatient evaluation of a lung mass for the previous two months. Laboratory studies suggested impending liver failure with a lactate of 14 mg/dL and a serum ammonia of 112 mcmol/L, bilirubin of 12.7 mcmol/L, and transaminases two to three times normal.
The patient’s performance status was ECOG 4 (in bed more than 50% of the time), and he was ambulatory prior to presentation. He was treated with oxygen, IV fluids, and parenteral and nebulized opioids. The patient was more comfortable but increasingly lethargic. He and his spouse wished for aggressive treatment, including cardiopulmonary resuscitation, pending diagnostic evaluation. A liver biopsy had revealed small cell carcinoma.
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Two physicians are involved in this case: Dr. O: a medical oncologist, 50-ish, with 20 years of experience treating patients with solid tumors; and Dr. PC: palliative care specialist, 30-ish, expert in pain and symptom management, patient decision-making and ethics.
Can they collaborate?
Dr. O: I saw the patient, discussed goals of care, and was frank about the situation. I told him he had a small chance of the cancer shrinking, days to live if he declined chemo, and a few months to live if he got chemo and the cancer shrank. The side effects of chemotherapy were relatively mild and if the chemotherapy did not work, he would be dead before he got neutropenic or had worsening liver failure.
I was torn because small cell lung cancer often shrinks dramatically with chemotherapy, even when the patient has poor performance status, liver failure and lactic acidosis. Chemotherapy would likely not make symptoms worse in the short term.
Dr. PC: The palliative care team discussed goals of care and reviewed therapeutic options. We felt he had a small chance of the cancer responding to chemo but were concerned he might not tolerate chemo given his liver failure. He likely had days to weeks to live if the cancer did not shrink or if he declined chemotherapy. He might have a few weeks to a few months to live if he got chemotherapy, the cancer shrank, and his liver failure improved.
The patient understood the prognosis and was emphatic: “I don’t want to die like my daddy did in the hospital. I want to go home.”
Other issues
The nurses were concerned about the wife’s ability to provide adequate physical care alone, as the mordidly obese patient required the assistance of three.
Dr. PC was most concerned about honoring the patient’s wish to die at home. The entire team was concerned about the wife’s functional impairment. She was grief-stricken and in denial about the patient’s prognosis and impending death. She clung to any hope of treatment, including chemotherapy, surgery or even a liver transplant.
The “Georgetown Mantra” of respect for autonomy, beneficence, nonmaleficence, and justice is widely accepted as a minimum standard for health care providers.
Respect for autonomy demands that care providers respect a patient’s preferences and recognize the right to self-determination.
Beneficence charges physicians with an obligation to act in the patient’s best interest. As his clinical status progressively declined, it was unclear if he even understood his surroundings and if transfer home was safe. Furthermore, if he was able to anticipate the care burden he would impose on his family, would he still want to go home at all costs?
Nonmaleficence prohibits physicians from harming patients, or at least intentionally making things worse.
Chemotherapy options were very limited given the patient’s severe hepatic dysfunction.
Dr. O: Dramatic responses of SCLC to chemotherapy may occur. Patients may have resolution of liver failure and lead decent lives for several months — but chemotherapy may also cause nausea, fatigue, and pancytopenia requiring reevaluation and admission. We knew the options, presented them to the patient and family, and let them make a choice. Most patients will opt for aggressive care, even with major side effects for a small benefit, but not all. The only way to know is to ask.
In this case, it was important for the family to hear that they were not being abandoned regardless of the decision not to treat with chemo. We were not “doing nothing,” but in fact we were honoring the patient’s wishes and had a plan for care that would maximally manage the patient’s symptoms and allow the patient to go home.
The PC teams makes my life easier in two ways: 1) They can help with the very difficult discussions and be an objective voice about chemo or not. 2) I was able to hand off those details to the team and they made it happen a lot more quickly than I could.
As the patient became increasingly moribund, sleeping most of the time and often not arousable, the window of opportunity for chemo therapy closed. The patient’s wishes to not die in the hospital mobilized the Palliative Care team, who made arrangements for home hospice care and assistance for his wife. He died peacefully within 12 hours of arriving home.
For more information:
- Thomas J. Smith, MD, is Chair, Division of Hematology/Oncology and Palliative Care, Virginia Commonwealth University, Richmond.
- Keith M. Swetz, MD, is a first year fellow in palliative medicine at Virginia Commonwealth University, Richmond.
References
- Alexopoulou A, Koskinas J, Deutsch M, et al. Acute liver failure as the initial manifestation of hepatic infiltration by a solid tumor: report of 5 cases and review of the literature. Tumori. 2006;92:354-7.
- Coyne PJ, Viswanathan R, Smith TJ. Nebulized fentanyl citrate improves patients’ perception of breathing, respiratory rate, and oxygen saturation in dyspnea. J Pain Symptom Manage. 2002;23:157-60.
- Matsuyama R, Reddy S, Smith TJ. Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol. 2006;24:3490-6.
- McGuire BM, Cherwitz DL, Rabe KM, Ho SB. Small-cell carcinoma of the lung manifesting as acute hepatic failure. Mayo Clin Proc.1997;72:133-9.
- Rice K, Schwartz SH. Lactic acidosis with small cell carcinoma. Rapid response to chemotherapy. Am J Med. 1985;79:501-3.