The prognosis for HCM is well-established. Generally, the patient has about eight weeks to live, unless it’s a newly diagnosed cancer that’s responsive to cancer-directed therapy.
With all of these conditions, some patients and families may choose to forgo intervention and allow natural death to occur, especially if the patient’s disease status is advanced and functional status is poor. In these cases, the role of the emergency department is to help patients access hospice services either directly from the department or early in their hospitalization.
A SECOND LOOK
Now, back to the case. Is this the active dying process, or is something else going on?
The patient’s calcium is 14. He’s a patient who would benefit from treatment for his symptom burden, as his functional status was good up until this incident. He’s given 2 L bolus of normal saline, then started on maintenance IVF and given 60 mg IV pamidronate over two hours.
His delirium improves over the next few days, and he is able to go home. During his stay, goals of care are revisited with the patient and family, as his prognosis is now approximately eight weeks. Hospice is introduced and accepted by the patient.
Identification of these cancer-related conditions and their prognostic significance empowers the emergency department and your patients to make the most appropriate health care–related decisions. End of life is difficult enough without an emergency added in.
Dr. Aberger is core faculty, emergency medicine/palliative medicine, for St. Joseph’s Regional Medical Center in Paterson, New Jersey. She is also chair for ACEP’s Palliative Medicine Section.
Dr. Fetzer is palliative care medical director at Rainbow Hospice and Palliative Care in Illinois.
Dr. Goett is assistant professor of emergency medicine and assistant director for advanced illness and bioethics at Rutgers New Jersey Medical School.
Dr. Rosenberg is chairman of emergency medicine, chief of population health, and associate professor clinical emergency medicine for St Joseph’s Healthcare System in New Jersey. He also serves on ACEP’s Board of Directors.