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The Patient's Story

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Mr K is a 66-year-old, African American man treated in the palliative care clinic of a university hospital for metastatic renal cell carcinoma. Mr K has been chronically homeless for most of the past 50 years. He sells drugs to support his daily cocaine and heroin use. He was in relatively good health until about 4 years ago when he presented to a nearby hospital with flank pain. The diagnosis based on biopsy results was renal cell carcinoma. The lesion was localized to 1 kidney. For unclear reasons, resection was made contingent on cessation of illicit drug use. After this examination, Mr K was lost to follow-up for almost a year, when he then presented to the emergency department with abdominal pain and heroin withdrawal. When questioned about the delay in treatment, he said that thinking about the diagnosis made him anxious. He was treated for severe hypertension with labetalol, and further evaluation showed bone metastases. He was evaluated for chemotherapy, but given the lack of anticipated benefit, Mr K opted to forgo it. Two months later, Mr K was first referred to the palliative care clinic. His physician, Dr E, focused on the challenges of controlling his pain while Mr K continued to use heroin and broached planning for the end of his life because Mr K lacked close friends and family and had no home. Although Mr K declined to enter a methadone maintenance program and has no stable place to stay, he keeps his appointments and has become more comfortable with clinic staff. He speaks frankly about his drug use, and as a consequence, he and his physicians created a safe and effective treatment program for pain and other symptoms. About his prognosis, he observes, "I did not expect to make it to age 21, never mind 66." He feels that he has had a full life, and his goal is to live as well as he can in the time that remains.

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Perspectives

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Mr K and his palliative care physician, Dr E, were interviewed by a Perspectives editor 18 months after he was first referred to the palliative care clinic.

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DR E: Mr K is a 66-year-old gentleman who was diagnosed 3 or 4 years ago with renal cell carcinoma. He has been homeless on and off for the past 50 years. Mr K has been a very heavy drug user. He has track marks all over his arms and if you ask him "Do you use intravenous drugs?" he says, "Yes." He is very straightforward about it. He continues to [use] heroin. He was living with a lady friend…but their relationship has come apart now. He is…probably going to be relocating to a shelter. He has a lot of trouble finding food, and so he kind of has to eat what he can get. But we do provide him with [canned liquid ...

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