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The Patient's Story

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Mr W is a 54-year-old man with a history of hypertension, bronchitis, and nephrolithiasis who presented 3 months before admission with increasing pain in his upper back. A magnetic resonance imaging study revealed a T7 vertebral body lytic lesion, suggesting a malignancy. He was admitted to the neurosurgical service of a university hospital for resection of the lesion, which proved to be adenocarcinoma. Further evaluation revealed a 2.8-cm lesion in the tail of the pancreas, multiple lung nodules, and rib lesions. Immediately after his T7 corpectomy and fusion, his course was relatively uneventful. The oncology and general internal medicine services were consulted.

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One week after the operation, during preparation for discharge to a rehabilitation facility, Mr W's respiratory status began to worsen. A pleural effusion was noted and a chest tube placed, draining 2 L of fluid. Despite drainage, however, the patient's oxygen requirements increased rapidly from 2 L/min of oxygen to 80% oxygen by face mask plus 6 L/min via nasal cannula. He was transferred to the medical service for further management.

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The medicine team was made aware of Mr W's wishes that he not be intubated or resuscitated and attempted to treat the possible underlying causes for his rapidly worsening respiratory status. Although he showed some improvement with bilevel positive airway pressure (BiPap), it was extremely uncomfortable for him.

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After continued chest tube drainage, broad-spectrum antibiotic coverage, and diuresis, computed axial tomography showed no pulmonary emboli, stable parenchymal nodules, improving effusion, and possible pleural metastasis. He experienced minimal improvement in his dyspnea. Eventually, however, his condition stabilized with 30 L/min of high-flow, vapor-phased, humidified oxygen by nasal cannula, which allowed him to talk, eat, and interact.

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After consulting with the oncology team, the medical team determined that Mr W would be a candidate for chemotherapy only if he were discharged successfully to home (that is, if his oxygen requirements could be reduced substantially from his inpatient requirements, and if he could undergo rehabilitation). This information combined with consistent inability to wean Mr W's oxygen left the medical team with few treatment options. At this juncture, the team initiated discussions with Mr W regarding his ultimate goals of care. He was very clear that he wanted to pursue all options available to him. The palliative care consultation service team was called in for consultation and assistance with end-of-life discussions and discharge options. Mr W stated that he expected God to miraculously extend his life for many years, and the consultation team interpreted that belief to indicate that hospice was not an appropriate option for him. Ultimately, Mr W's oxygen requirement was tapered to 12 L/min via nasal cannula, and he was discharged to a skilled nursing facility.

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Perspectives

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A Perspectives editor interviewed Mr W, his attending physician Dr D, and Rev S, the palliative care service chaplain.

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