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The Patient's Story

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Reverend J was a 75-year-old former hospital chaplain who was well until he developed dyspepsia, anorexia, nausea, and vomiting 4 months before admission. Three months before admission he was admitted to hospital A, a community hospital, and was diagnosed as having widely metastatic adenocarcinoma involving the stomach, liver, and pancreas with biliary obstruction. A biliary stent was placed. At the time of diagnosis, his wife reports being told, "if he made it 2 months, it would be a miracle."

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One week before admission he had waxing and waning mental status and increased somnolence. With worsening symptoms and pain, his wife brought him to the emergency department of hospital B, where he had been chaplain for many years, although his insurance plan did not include that hospital. Evaluation showed severe hyponatremia (sodium, 108 mEq/L [108 mmol/L]) and jaundice (total bilirubin, 26 mg/dL [445 μmol/L]). He was treated with intravenous saline in the emergency department and transferred to hospital C, the local university hospital, for comfort care.

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Reverend J was admitted from hospital C's emergency department to the palliative care unit. Goals of care were established with the patient and wife. These goals included freedom from pain, nausea, and vomiting, as well as some time for the rest of the family to gather and to cope with his impending death. The patient was treated with a combination of piperacillin and tazobactam for a presumed bacterial infection and 3% sodium chloride intravenously for hyponatremia. His delirium was treated with a trial of lactulose administered via nasogastric tube. Intravenous morphine was titrated to achieve pain control. Antiemetics were administered for nausea. Blood cultures and other diagnostic tests were not obtained because they would not change management. Nursing, social work, and chaplaincy staffs worked intensively with the patient and family. Intravenous antibiotic therapy was discontinued when the patient and family were gathered and ready to make that decision. Reverend J died 5 days after admission.

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Perspectives

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MRS J: My husband went to the doctor in April complaining about not being able to keep food down, and they did a series of tests, and when the results came back they diagnosed him with cancer of the liver, stomach, and pancreas, and [told him] he had 2 to 6 months to live. [After he was diagnosed at hospital A] they said they was going to make him comfortable. [When they sent him home from the hospital] the doctor sent the bottle of morphine here, and that was it. [On the day he was admitted to hospital C] I said, "I'm desperate." We drove up at 12:30 am to the university hospital's emergency department.

DR A: Too many times we saw people that were dying in ways that we thought weren't optimal and so many times found ourselves trying to jury-rig a good setup for families and patients. While we could provide the right kind ...

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