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The Patient's Story

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Mr L was a 56-year-old, previously healthy businessman who presented with progressive back pain. Vertebral biopsy revealed poorly differentiated non–small cell (squamous cell) lung cancer. His vertebral metastases and multiple asymptomatic brain metastases were treated with dexamethasone and radiation therapy.

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After discussing prognosis and options with his oncologist, Dr O, he received chemotherapy with weekly gemcitabine and carboplatin. He tolerated treatment well, and for 4 months on this therapy his cancer did not grow. When the disease progressed, he was switched to erlotinib orally. This prevented further cancer growth for almost 6 months, during which time he was asymptomatic, except for a mild rash and diarrhea. For a few months, he was able to travel and lead a normal life. However, 10 months after initial presentation, Mr L's cancer again progressed. His chemotherapy was switched to pemetrexed but the tumor continued to grow.

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Eleven months after initial presentation, Mr L developed diplopia, and meningeal carcinomatosis was confirmed the following month when magnetic resonance imaging (MRI) of the brain showed enhancement of the fifth, seventh, and eighth cranial nerves. In the few days Mr L took to discuss his care with his medical student son, he progressed from manageable double vision to needing a wheelchair and becoming incontinent. An Ommaya reservoir was placed, and Dr O started the patient on twice-weekly intrathecal methotrexate. He improved slightly, then remained stable for 2 months, enough to return to work part time and to travel a bit. Soon progression of the leptomeningeal disease resulted in additional cranial neuropathies. The intrathecal therapy was changed to liposomal cytarabine. Mr L continued to want active therapy; he attempted to enter a clinical trial for an investigational central nervous system chemotherapeutic treatment but was not accepted because of his general debility.

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In the month before hospital admission, Mr L had a rapid decline with less appetite and reduced ability to walk. After several falls, he required a wheelchair for mobility. Three months after meningeal carcinomatosis was diagnosed, he was admitted to the hospital for aspiration pneumonia and hypoxemia. At the time of admission, Mr L was a "full code" and had appointed his wife as durable power of attorney for health care decisions. The patient and family had been considering hospice, as suggested by the oncologist, and had been visited at home by a hospice intake worker. However, the patient wanted to continue fighting the disease instead of entering hospice.

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On examination, Mr L was a chronically ill–appearing man whose breathing was aided by nasal oxygen and who sat on a bedside "neuro" chair. He had a fourth cranial nerve palsy and disconjugate gaze, facial droop, hoarse voice, absent gag reflex, and coarse breath sounds. A chest radiograph showed multiple pulmonary nodules and a new patchy left lower-lobe infiltrate.

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The medical house staff called a palliative care specialist, Dr A, who noted that ...

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