Pediatric emergency medicine trisk 2748 2748
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Approaching patients with advanced cancer requires the clinician to acknowledge
that sometimes patient/family preferences do not seem aligned with those of the
healthcare team. For example, the clinician may encounter a patient who is clearly
within hours or days of death but who still “wants everything done,” including
cancer-directed therapy and aggressive management such as intubation or
resuscitation. On the other hand, the clinician may instead face a patient with
seemingly good functional status and quality of life who declines further diseasedirected treatments. Cases may exist anywhere in between these two extremes. It is
the clinician’s responsibility to provide honest and complete information and elicit
the patient’s beliefs and wishes to facilitate decision making that most reflects the
wishes of the patient and family. Once decisions are made, it is then the duty of the
clinician to help carry out those wishes. Patients with advanced cancer may have
clear preferences regarding admission to the hospital. While some patients and
families may have adequate services in place to remain in their homes, some will
still desire inpatient management as a form of respite.
Initiation of a management plan intended to reduce symptoms is always an
appropriate step. The kind of intervention best able to reduce symptoms must be
chosen based on the goals of care. Patients with advanced cancer have often
received large amounts of opioids in the past and may therefore require larger doses
of pain medications than routinely administered to children in the ED (see “Pain”
section). It is imperative for the clinician to increase the opioid dose until an
efficacious dose is reached. Opioids may also be carefully titrated to treat shortness
of breath or other respiratory symptoms.
Diagnostic workup and specific management beyond symptom control should be
undertaken in a manner consistent with the goals of care. If the patient’s focus is
only on comfort, then additional testing should be considered only if it will help
identify a reasonable strategy to optimize that comfort. Consider, for example, a
patient who presents for pain management but who is also cachectic and dehydrated.
The clinician may wonder whether checking serum electrolytes and initiating
rehydration are indicated. If the stated goals of care are comfort, then these measures
should be omitted since electrolyte disturbances rarely cause pain or discomfort and
hydration often will prolong the suffering associated with severe pain at the end of
life. Indeed, hydration could increase edema or secretions that would actually
decrease quality of life. As an additional example, consider a patient presenting with
a malignant pleural effusion causing severe respiratory distress. Under other
circumstances, the management of a large effusion might be immediate placement of
chest tube. In this case, the clinician might instead ask, “How will a chest tube help
this patient and does it match what he/she wants?” This change in thought process is
often extremely hard for healthcare providers whose experience and training do not
