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The Patient's Story

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Mr K is a 49-year-old man with metastatic spindle cell cancer who was admitted directly to the palliative care service of a large metropolitan hospital for management of intractable pain, following a week of telephone consultation between his primary care physician and the palliative care service. The palliative care service provides more than 400 consultations per year in a 1900-bed hospital that is part of a health care system that includes both home care and hospice programs. The palliative care service team consisted of 3 physicians, a clinical nurse specialist, a social worker, and a chaplain.

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The patient's primary care physician had tried treating Mr K's pain with long-acting opioids (long-acting oxycodone, 340 mg twice daily) and dexamethasone but without success. The patient had a complex history of back problems dating to adolescence, with a diagnosis of spindle cell sarcoma 1 year earlier. The tumor had progressed to involve the T2, T3, and T4 vertebrae. Because of instability, 1 of the patient's ribs was harvested and wrapped in a titanium cage in an attempt to stabilize his spine. However, after surgery, the harvested rib slipped, requiring that the operation be performed again 4 days later. He was then referred to a quaternary care facility for 16 rounds of proton beam therapy, returning home 2 months before the interview. Since then, his pain had been escalating, and magnetic resonance imaging (MRI) revealed malignant involvement of the T1, T5, T7, and T9 levels. Despite long-acting opioids and dexamethasone, he now rated his pain as "10 out of 10" and at times wondered how he could go on and bear the pain.

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Mr K is a retired engineer and has received disability payments since his mid 30s. His wife is a psychiatric nurse and acupuncture practitioner. Mr and Mrs K have 3 sons, aged 18, 13, and 12 years. Mr K is Lutheran and his beliefs provide him solace.

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On admission, the palliative care physician, Dr G, noted that Mr K and his wife requested visits from both the social worker and chaplain. Mr K's goals were improvement in pain and longevity, although he acknowledged his terminal illness. Mr K expressed his desire for "full code" status, although he understood the concern that chest compressions could result in spinal paralysis. On admission, Mr K shared his concern that he be present at his middle son's Eagle Scout induction the following weekend.

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Within a short time, the palliative care service team addressed a number of important family issues. First, Dr G outlined a care plan and instilled a sense of hope regarding pain management options. A temporizing pain regimen of methadone, ketamine, and a single intravenous dose of zoledronic acid was instituted and provided relief. An interventional radiology procedure to place a catheter for intrathecal opioid administration was arranged for the Monday after the Eagle Scout ceremony. Second, noting the previous fragmentation ...

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