James Benton, a 58 year old man, with a rapidly progressing metastatic gastric
cancer comes to the Emergency Room of a large university hospital for nausea,
vomiting, and severe abdominal pain. Mr. Benton had been seen by a community
oncologist and had been treated with several rounds of chemotherapy with no
response.
During his most recent clinic visit, his oncologist had recommended stopping
any further chemotherapy and wanted to refer Mr. Benton to hospice. But Mr.
Benton, a very wealthy businessman with a Type A personality refused any discussion
of hospice care, brooked no talk of giving up anything -- he was "a fighter".
View the following simulated case on video, paying attention to the interactions
and effectiveness of communication between the hospital staff and the patient.
In the ER:
ER Doc: "Mr Benton, can you please tell me about your goals of care.
As you know, you have a gastric cancer that is spreading very fast and...."
Mr. Benton: (interrupting the physician angrily) "Doc, that is why I
came here as you have one of the best cancer centers in the country. I want
the 'works'. Do what you have to, life support, defibrillators, experimental
drugs, whatever.... I want my pain treated and I want to get better as soon
as possible."
In the hospital:
Day 1: Mr. Benton is diagnosed with malignant bowel obstruction and is admitted
to the Oncology Service. The Oncology Attending feels that patient is not a
candidate for any further therapy and consults Palliative Care for "help
with goals of care, symptom management and to educate the patient about the
dying process." Surgery has determined that patient is not a surgical candidate.
All involved clinicians felt that the patient had a life expectancy of a few
days given the advanced state of his disease.
Mr. Benton complains of "10/10 pain and severe nausea" to the Palliative
care physician, Dr. Scott. Dr. Scott agrees that the patient has a life expectancy
of " days to weeks" and makes the following recommendations to medically
manage the malignant bowel obstruction:
Stop IV fluids.
Stop NG suction.
Start the following medications: Fentanyl transdermal patch 25 micrograms
per hour, octreotide 200 micrograms IV every 12 hours, ondansetron 2 mg IV
push every 4 hours as needed, fentanyl 10 micrograms IV push every 4 hours
as needed for breakthrough pain.
Hospitalization:
Morning of Day 3: Mr. Benton reports that he is now pain free and has very
minimal nausea. He has started to eat small quantities of low-fiber pureed food
for pleasure and he is sleeping well. Dr. Scott and Nurse Betty Roberts walk
into his room during "rounds".
Dr. Scott: (smiling): "Good morning James. I heard that you had a
good night's rest and that you are pain free. How are you feeling?"
Mr. Benton (angrily): "If you can’t do anything better than
this, than you might as well just kill me. I don’t care that my pain is
gone, I don’t care that the nausea and vomiting are gone. If I’m
spending the rest of my time lying in this bed, you might as well just kill
me."
Dr. Scott looks completely taken aback! Nurse Roberts looks on and does not say
anything.
