Your patient has terminal metastatic cancer. In his record, you find a Physician Order for Life-Sustaining Treatment (POLST) form that clearly documents his wishes for symptomatic treatment only: Allow a natural death; do not intubate; do not perform CPR. However, he isn’t enrolled in hospice because he’s still receiving oral chemotherapy. On exam in the emergency department, he’s in extremis, and so is his family. You’re worried he may be dying, but he isn’t going gently into that good night.
What’s your approach?
DEFINING THE EMERGENCY
First, you need to obtain more information from the family. The patient has been relatively functional until today, still walking with assistance and eating, but not a lot. Yesterday, he complained of mild nausea, but this morning, there was an acute change where his mentation was altered and he was unable to ambulate.
But are there medical emergencies at the end of life?
It turns out that there are. Antiquated thinking is that “do not resuscitate” (DNR) equals “do not treat.” This has changed significantly.
Today, there’s wide acceptance of palliative care and its aggressive symptom management, especially at the end of life. We’ll highlight four cancer emergencies that need to be recognized and managed by emergency physicians: 1) spinal cord compression, 2) pathological fracture, 3) superior vena cava syndrome, and 4) hypercalcemia of malignancy.
Spinal Cord Compression
Spinal cord compression (SCC) is most common in metastatic bone cancer. The first symptom is pain, followed by weakness of the extremities involved. The compression is most often from edema or tumor compressing on the dural sac. The gold standard for diagnosis is MRI, but in the setting of severe pain, it’s often difficult for the patient to tolerate this test because of positioning and time. For initial assessment and disposition planning, CT can give you the answers you need more quickly.
There’s a subset of end-of-life patients who will benefit from surgery:
- if they have a prognosis of three months or more
- if the paralysis has lasted fewer than 48 hours
- if there is non-radiosensitive cancer
- if there is an isolated area of SCC
In these patients, the benefits of restoring functional status may outweigh the risk of surgery. For patients who wouldn’t benefit from surgery, another treatment option is radiation therapy (RT). A single dose of RT has been shown to alleviate pain and possibly restore function. Remember to aggressively treat your patient’s pain with parenteral opioids while obtaining your diagnostics and formulating an appropriate treatment plan. With intervention, SCC patients can ideally expect an approximate three-month survival with improved pain and weakness. Without treatment, the general prognosis is one-month survival with limited quality of life.