Palliative Care

What are we thinking? Part 1

My patient was a 69 year old lady with metastatic small cell lung cancer. She was on experimental chemotherapy and was admitted from clinic with worsening lower extremity edema and a new oxygen requirement.  She underwent a chest and abdominal CT that revealed new pulmonary masses, tumor and a mass invading her right pulmonary artery, a new loculated pleural effusion, and acute thrombus in the IVC that was occluding her hepatic veins as well as extending into her iliac veins bilaterally.  She was tachycardic and tachypneic.  Every time she moved, despite supplemental oxygen, she desaturated into the 60 percent range. OK, pop quiz:  What is the answer to this patient management problem? If you have answered the word "hospice," you are right. I spoke with the outpatient oncologist, the palliative care team,  and had a meeting with the patient and her daughter explaining the lack of clear therapeutic options. They…

The Gift of Cancer

From the start, let me say that I do not mean to imply that anyone diagnosed with cancer or any other disease is lucky for having received the diagnosis. I also want to emphasize that there is a tremendous spectrum that anyone living with cancer can experience, from benign to devastating. The word “cancer” has a lot of power in our culture.  It can hang as a black cloud over our lives or the lives of loved ones.  We may think of powerlessness, uncertainty, death, pain, suffering, weakness, debility, or a host of other fearful connotations. It is almost assured to suck the air out of any conversation when it comes up. When someone I have not seen in a while asks, “What’s new?” I have to decide whether to bring up the CLL diagnosis and let that hijack the conversation, or to leave it unsaid. But cancer can also…

Do You Want Us to Do Everything, Or…

“One more question:  do you want us to do everything, or do you just want palliative care.”  The first syllable of the word “palliative” emphasized, drawn out, left hanging.  This is one version of the five-second, halfhearted code status discussion for seriously ill patients being admitted to the hospital with either a new disease or an exacerbation of an existing one.  We all have phrases that grate on our nerves, and this is one of mine. There are similar statements that are not much better.  “Well, we’ve done all we can, how about palliative care?”  Or, “You know, I think it’s time to go the palliative route.”  These are sometimes said as providers are backing out the door, mentally and physically disengaging from their patients. We have a problem in our culture with discussions about end-of-life and advanced care planning.  Politicians and pundits use distrust of the healthcare system to…

What’s in a Number – Part I

119 – that’s one of my numbers. 3.5 - that’s another one. One hundred and nineteen months is the most recent estimate I could find for median survival for CLL.  Three and a half years is the most recent median time from diagnosis until the first treatment is needed. These numbers recently became “mine” after a diagnosis of chronic lymphocytic leukemia this past June.   But what do the numbers actually MEAN? First some context:  I was in Vietnam on a work trip when I noticed the cervical and axillary lymphadenopathy.  I ignored it for another month until a “curbside” with a friend and colleague who encouraged me to actually get it worked up. I was in the midst of a busy and stressful week on our academic hospitalist service, trying to do my best to teach, lead the team, care for patients, and move people through admission to discharge in…