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The Patient's Story

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Mr D was an 84-year-old man with metastatic melanoma who was hospitalized for a rapid decline in functional status and diminished oral intake. On admission, he was intermittently able to follow commands and had a left facial droop. He was dehydrated and received intravenous fluids. Other causes of functional decline, such as infection, hypothyroidism, or hypercalcemia, were excluded. Central nervous system imaging confirmed multiple enlarging metastases.

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Diagnosed as having melanoma 3 years earlier, Mr D had declined biopsy and potentially curative surgery. Metastases to his adrenal glands and brain were confirmed during the year before admission, and he received palliation with radiation and corticosteroids.

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Mr D was admitted from home, where he lived with his wife of 58 years. They had no children, and the patient's only other close family members were 2 physically frail sisters. His wife was his durable power of attorney for health care. However, she had dementia, and her capacity to continue fulfilling this role was uncertain. Mr D's physician estimated his life expectancy to be "days to weeks," depending on nutritional intake. When Mr D resumed eating and drinking small amounts, the physician recommended discharge to a nursing home. The family expressed a desire for Mr D to stay in the hospital until his death, which was untenable for financial reasons. The family's other major priority was location—they wanted to find a facility close to Mr D's home so that they could visit daily.

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Perspectives

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A Perspectives editor interviewed Dr T, Mr D's palliative care physician in the hospital, and Ms R, the director of nursing at the nursing home to which Mr D was discharged.

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DR T: Mr D is an 84-year-old man with metastatic melanoma to the brain and the adrenal glands…[His disease had] gone on for 3 years with metastases. At this point there were no further aggressive curative treatment options. He was admitted right after Thanksgiving, with a history of about 4 days of markedly diminished oral intake. He was unable to care for himself at home. He had become progressively weak, slurring his speech, had difficulty expressing himself. He was really unable to get around…So the main thing was to gear up some palliative treatment options and a good care situation…We [the palliative care consult team] were called in right after Mr D was admitted to give the family information about hospice options. The prognosis was probably weeks. Medicare would pay for an acute hospital stay for an acute hospital need, but they wouldn't pay enough for an acute hospital stay for hospice-level care, and therefore the family would end up with a huge hospital bill. His wife is also diminished in her capabilities because she has multi-infarct dementia. It was pretty clear that his 2 sisters, who were even older than he, weren't going to be able to care for ...

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