End of Life Treatment for Patient With Terminal Cancer

C.G.

The history of C.G. is that he is a former smoker, 69-year-old male with cancer in the head and neck (a radical neck dissection was performed in 2012), which has recently metastasized in the liver and lungs, as indicated by PET scan which shows metabolic activity. The patient suffers from moderately-severe depression with a PHQ-9 score of 15 (Kroenke, Spitzer, Williams, 2001) and refuses anymore chemotherapy. He is at a point now where he wants to know his options for what remains of the rest of his life, indicating that he is not willing to undergo any further treatment for the his cancer or its spread.

The results of the physical show that C.G. suffers from hypertension, hyperlipidemia, stomatitis, anemia, and neutropenia. He is currently receiving 12.5 mg of Carvedilol daily plus 40 mg of Furosemide daily. His BP indicates that he has "isolated systolic hypertension" and it is likely that the treatment for and failure to stop the spread of his cancer has contributed to the stress that his body his under, which is registered in his mental and emotional fatigue and desire to cease all treatment for the cancer. The rest of the physical has not revealed any serious problems or defects other than the expected limited range of motion in the head/neck and Ronchi detected in the lungs.

The differential diagnosis suggests liver cancer, adjustment disorder, and chemotherapy side effects, but the primary diagnosis is metastatic cancer. The rationale for the primary diagnosis is the evidence of metabolic activity in the liver and lungs as well as in the neck, indicating that the cancer has indeed spread throughout the body (Berman, 2004). The rationale for the differential dx -- liver cancer -- is based on the same indications but ignores the possibility of the spread of the cancer from the neck (Berman, 2004). Likewise, adjustment disorder does not consider the metabolic activity and is based solely on the patient's depression and desire to discontinue treatment as the therapy does certainly take a toll on the body and the mind (Aragon-Ching, Zujewski, 2007).

This differential diagnosis does not suggest that such is not happening, only that the liver cancer is unrelated, and that the adjustment to the chemo therapy has not gone well, as indicated by the PHQ-9 results and the patient's desire to cease all treatments plans. Nonetheless, the metabolic activity is indicative of the spread of the cancer from the neck and not merely an unrelated cancerous development (Berman, 2004). Also the likelihood of chemotherapy side affects is not dismissed as this is also very likely a possibility; however, it is not a sufficient diagnosis or explanation for the spread of metabolic activity in the liver and lungs.

Secondary diagnosis includes hypertension, somatitis, Anemia, Neutropenia, Hyperlipidermia, effects of tobacco use, and right head and neck cancer. The rationale for these diagnoses are found in the effects of unhealthy lifestyle (smoking, diet) as well as age and stress factors linked to the radiation therapy, which accounts for the Neutropenia too (Davis, Squier, Lilly, 1998).

At this point, because the patient is refusing further treatment, the complete treatment plan is focusing on quality of life and suggests preparing the patient and the family for the coming end of life for C. G. At this time care should be taken to consider how best to utilize the remaining time and to provide comfort and consideration to the patient and family members who will be with him. Care giver information should be secured from hospice as an alternative if necessary, for help with medications to ease the pain of the patient as well as to assist family members.

Education of the patient and the family should commence immediately, explaining the expected results of ceasing all treatment, which will allow the cancer to spread more rapidly.

The medication to be provided should be the continued prescription of Carvedilol and Furosemide but in the coming days and weeks a prescription of morphine will be given in order to reduce the effects of the pain.

The ICD-9-CM code is 199.1 for metastatic cancer.

A referral should be given to a behavioral-psychology department so that the patient and his family may receive treatment for the concomitant depression surrounding this case. The patient is seen as having moderately-severe depression and this should be treated separately from the cancer treatment. However, it is likely that the depression is linked to the chemotherapy and the failure of the therapy to eradicate the cancer. Nonetheless, alternative measures and patient education should include supplemental material on settling life affairs, such as getting a will in order and matters of the estate which could prove problematic for surviving family members if not settled. Also a living will should be discussed with the patient even if these matters are unpleasant and possibly causing of more depression. They should be brought up with sensitivity but firmness, with the importance of them being shown to the patient and the result of their being written showing that they will actually reduce the stress in the patient's life by relieving the mind of various burdens that as of yet have not been attended to.

Finally, it should be recommended that if the patient chooses to be at his home in his final days that the family should prepare for this either by enlisting hospice or discussing a medical plan with the doctor and identifying needs and strategies for the coming days and weeks as well as what to expect for the patient.

A plan for a follow-up should include monitoring of the patient's pain levels as the patient has refused a continuation of therapy, as well as his mental health in the coming days, which should be maintained as best as possible to facilitate the execution of practical needs that will affect the family, as determined by the patient's focus on matters of inheritance, etc. (Aragon-Ching, Zujewski, 2007).