A 61-year-old man who manages his own accounting firm has a 5 year history of malignant melanoma that has been treated with local excision and immunotherapy. He now is admitted to the hospital for evaluation of constant pain in his back and left hip and an 11 kg (24 lb) weight loss. He and his wife of 35 years are worried that "the cancer may be back." Pelvic and abdominal CT scans show multiple bony metastases. He tells you, "I just want to die. I can't bear this."
Which of the following is the most appropriate initial intervention?
Correct Answer A:
The patient is medically unstable, should remain on a medical service, and should not be transferred to a psychiatric service. Pain is the number-one cause of suicide in the terminally ill and decreasing the pain by maximizing analgesia will help the patient face dying with dignity. Providing adequate pain relief when you are dealing with a terminally ill patient is crucial to maintaining the highest possible quality of life. If this man’s pain is this severe, then adjusting the analgesic regimen is the only logical step. There is no evidence of a clinical syndrome of major depression so an antidepressant is not indicated.
Hyperalimentation may be needed if the patient is not eating, or is unable to eat. This is most likely due to chemotherapy, or pain or cachexia secondary to cancer. Decreasing the pain can result in increased appetite. A cancer patient support group will be useful in the long run, but will not help the patient until the acute crisis is resolved, namely the wish to die.
An 85-year-old white male with terminal pancreatic cancer is expected to survive for another 2 weeks. His pain has been satisfactorily controlled with sustained-release morphine. He has now developed a disturbed self-image, hopelessness, and anhedonia, and has told family members that he has thought about suicide. Psychomotor retardation is also noted. His family is supportive. His daughter feels that he is depressed, while his son feels this is more of a grieving process.
Which one of the following would be the most appropriate management of this problem?
Correct Answer E:
Distinguishing between preparatory grief and depression in a dying patient is not always simple. Initially one should evaluate for unresolved physical symptoms and treat any that are present. If the patient remains in distress, mood should be evaluated. If it waxes and wanes with time and if self-esteem is normal, this is likely preparatory grief. The patient may have fleeting thoughts of suicide and likely will express worry about separation from loved ones. This usually responds to counselling.
In patients with anhedonia, persistent dysphoria, disturbed self-image, hopelessness, poor sense of self-worth, rumination about death and suicide, or an active desire for early death, depression is the problem. For patients who are expected to live only a few days, psychostimulants such as methylphenidate(choice E) should be used. For those who are expected to survive longer, SSRIs are a good choice. This is because SSRI are the best drugs for the management of long-term depression.
→ Fluoxetine (choice A) and Sertraline (choice B) are SSRI that would be more appropriate for the management of long-term depression. SSRI usually do not manifest their effects until 2- 3 weeks into treatment, so this patient would have died by the time SSRI would start to have benefits.
→ Clozapine (choice C) and Olanzapine (choice D) are atypical antipsychotics.
A 63-year-old white female with ovarian cancer is approaching death. She is unresponsive, begins to retain pulmonary secretions, and develops harsh gurgling.
The best treatment for this patient would be:
Correct Answer C:
As the level of consciousness decreases in the dying process, patients lose their ability to swallow and clear oral secretions. As air moves over the secretions, which have pooled in the oropharynx and bronchi, the resulting turbulence produces noisy ventilation with each breath, described as ‘gurgling ‘or ‘rattling noises.’ This patient has terminal congestion, often called the “death rattle.” Other than positioning on the left side, this is best treated with anticholinergics such as scopolamine, hyoscyamine, glycopyrrolate, and atropine.
→ Reduction (not increase) of fluid intake is part of non-pharmacological treatment.
→ An expectorant is not indicated when the patient is unresponsive.
→ There is no bronchospasm, so albuterol would not be helpful.
→ Oxygen is indicated for hypoxia and would not be useful in the treatment of terminal congestion.
Which one of the following is true regarding the use of opiates in terminally ill patients?
Correct Answer B:
In terminally ill patients, the most common physical symptoms are pain, fatigue, and dyspnea. Opiates are useful for controlling pain and relieving dyspnea as well. Even small doses of a weaker opiate can reduce the sensation of shortness of breath in cancer patients and in those with heart failure or chronic obstructive lung disease.
Addiction is rare in terminally ill patients who are being treated with opiates for pain and/or dyspnea. A medication contract between physician and patient is not required by law and generally is not necessary in this situation, unless diversion of the medication from the patient by the caregivers is suspected. Constipation due to decreased gastrointestinal motility is a very common, if not universal, side effect. Respiratory depression is a late, not early, sign of excessive opiate dosage. Another sign of opiate excess, pinpoint pupils, occurs before respiratory depression and is therefore a useful parameter for monitoring these patients.
Which of the following is false with regard to falls in the elderly?
Falls are the leading cause of injury-related visits to emergency departments (choice A) and the primary etiology of accidental deaths in persons over the age of 65 years. The mortality rate for falls increases dramatically with age in both sexes (choice B) and in all racial and ethnic groups, with falls accounting for 70% of accidental deaths in persons 75 years of age and older. Falls can be markers of poor health and declining function (choice D), and they are often associated with significant morbidity.
More than 90% of hip fractures occur as a result of falls, with most of these fractures occurring in persons over 70 years of age. In persons over age 75, fractures of the lower extremity are about twice as common as fractures of the upper extremity (statement in choice C is incorrect). One third of community-dwelling elderly persons and 60% of nursing home residents fall each year. Risk factors for falls in the elderly include increasing age, medication use, cognitive impairment and sensory deficits. Outpatient evaluation of a patient who has fallen includes a focused history with an emphasis on medications, a directed physical examination and simple tests of postural control and overall physical function.
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