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B. Michel
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ED06 - Symptom Management in Lung Cancer (ID 269)
- Event: WCLC 2016
- Type: Education Session
- Track: Palliative Care/Ethics
- Presentations: 1
- Moderators:R. Gralla, R. Malayeri
- Coordinates: 12/05/2016, 16:00 - 17:30, Stolz 1
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ED06.06 - Decisions in Case of Intractable Symptoms (ID 6452)
17:15 - 17:30 | Author(s): B. Michel
- Abstract
- Presentation
Abstract:
Case report A 55-year-old lady was diagnosed with small cell lung cancer in late 2008. She had been a long-time cigarette smoker without, any other significant medical history. She was a housewife, deeply religious and dedicated mother to 2 children. As a first treatment for her cancer, she received radiotherapy on the right apex and mediastinum, concomitantly with chemotherapy (cisplatin plus etoposide), early in 2009. Six months later, she presented a very painful right shoulder and chest wall. Chemotherapy was resumed, with some improvement of the pain, but late in 2009, radiotherapy had to be administered to the chest for uncontrolled pain; oral etoposide was given without much benefit. The pain progressively increased and the patient was complaining of increasing shortness of breath. As the tumour was clearly progressing, in 2010, with further lung, bone and liver involvement, a decision was made to discontinue any specific oncological treatment. Both symptoms pain and dyspnea increased in intensity and became uncontrollable late in 2010; the patient and her family requested sedation at any cost. The patient was started on palliative sedation and died peacefully after 2 days; with her family present. Supportive and palliative treatments for pain Table 1 summarizes the time evolution of the patient and the corresponding interventions as far as analgesics and co-analgesics are concerned. Management of dyspnea over the course of her disease, the patient experienced progressive dyspnea which could be managed with oxygen, corticoids, benzodiazepines and bronchodilatating aerosols, as well as physical therapy and hypnosis. Dyspnea became major and beyond control the day prior to the last hospitalization and was a reason for accelerated sedation. Figure 1 Management of depression The patient had multiple reasons for being severely depressed: her mother was experiencing lung cancer at the same time ; the patient was concerned about becoming increasingly a burden for her family; she was aware of her worsening condition and realizing that her life would end soon; she was extremely anxious to have to die in intractable pain. The management of the patient’s depression included the following: monthly consultation with an onco-psychiatrist and weekly visits to a psychologist-social worker ; psychotropic drugs ; several sessions of hypnosis. Palliative sedation That the control of the patient’s pain and/or dyspnea might require palliative sedation has been discussed since 2010 (time of worsening of her symptoms) between the patient, her family and the caregivers. The patient and her family spoke openly about end-of-life issues, always emphasizing not to let the patient die in severe pain. After making the decision to resort to sedation in case of intractable symptoms, the patient and her family expressed a sense of relief that her suffering could and would be alleviated. When the patient expressed unbearable pain and dyspnea, the mobile nursing team started her on midazolam, scopolamine and methadone by sub-cutaneous route, with no clear-cut response; the patient was brought to the hospital, where the same medications were given intravenously, with the addition of haloperidol. No attempt to lift the sedation process (respite sedation) was made, according to the patient’s will. The patient was able to rest comfortably and died peacefully after 2 days, with her family at her side. Discussion In case of dyspnea due to lung cancer progression, corticosteroids, morphine and oxygen are used since many years ; novel options were introduced timidly during the last years. These new options include non-invasive ventilation, high-flow oxygen and rational use of medications usually prohibited in patients with respiratory distress, such as benzodiazepines, antidepressants and synthetic opioids [1]. The World Health Organization (WHO) scale for cancer-related pain proves to be an effective approach to pain management in cancer patients [2], and many variations based on it have been proposed [3]. However, these approaches represent pragmatic and empiric attitudes that are rarely evaluated in prospective studies. There is also a lack of consensus about the use of co-analgesia and other supportive approaches for refractory pain [5]; although pragmatic recommendations exist, a comprehensive algorithm for the management of refractory pain is still lacking. Based on the experience in our supportive care unit, we proposed a comprehensive model for the progressive management of pain in cancer patients (Figure 1). Finally, the approach to pain (or other symptoms) that is beyond medical control, fortunately a relatively rare situation, has not been clearly defined [6;7]. Palliative sedation or euthanasia is always an emotionally and ethically challenging event for all involved and implies to meet the needs of the patient and family but also those of the caregivers [8; 9; 10] and requires repeated and professional counselling with the patient and family as well as regular debriefing sessions with the medical and nursing teams. Although the decision to offer and provide palliative sedation or euthanasia (if requested by the patient and not illegal) is never easy, it should be seen, however, as the medical duty to safeguard the patient’s autonomy, the principle of individual freedom to make choices. Figure 2 References 1. Cabezón-Gutiérrez L, Khosravi-Shahi P, Custodio-Cabello S, Muñiz-González F, del Puerto Cano-Aguirre M, Alonso-Viteri S. Opioids for management of episodic breathlessness or dyspnea in patients with advanced disease. Support Care Cancer 2016;24:4045-55 2. Meuser T, Pietruck C, Radbruch L, Stute P, Lehmann KA, Grond S. Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 2001; 93:247-57 3. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 1995; 63:65-76 4. Swarm RA, Abernethy AP, Anghelescu DL, et al. Adult cancer pain. J Natl Compr Canc Netw 2010;8:1046-86 5. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid –induced hyperalgesia. Pain Physician 2011; 14:145-61 6. Council on Scientific Affairs, American Medical Association. Good care of the dying patient. JAMA 1996;275:474-8 7. Field MJ, Cassel CK, eds. Approaching death: improving care at the end of life. Washington DC: : National Academy Press, 1997 8. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life : a literature review and recommendations for standards. J Palliat Med 2007; 10:67-85 9. Olsen ML, Swetz KM, Mueller PS. Ethical decision-making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proc 2010;85:949-54 10. Lossignol D. End-of-life sedation: is there an alternative? Curr Opin Oncol. 2015;27(4): 358-64
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