A reader sent me this picture of metastatic small cell lung cancer manifested as skin mets:
There's something you don't see every day. I saw this patient in consultation for the attending oncology service. The patient was getting palliative chemotherapy for the last month or so. I'm not an oncologist and don't claim, by any means to know all the nuances for treatment. But someones gotta help me understand why give any chemo at all to a guy with systemic mets in liver, bone, kidney, mesentery, skin. Severe cachexia, severe protein malnutrition, with an albumin of less than 2 and a compensated ischemic cardiomyopathy with an ejection fraction of 15%.
Someone needs to help me understand what the purpose of any chemo at all as opposed to straight up hospice cares. While I find it hard to believe, the patient says nobody offered him the option of no treatment at all. The patient discharged in 24 hours to hospice after a palliative care consult. It seems silly but we just spent over $10,000 in Medicare dollars, easily, for him to come to the hospital, get worked up for back pain, to get an MRI, medications, nursing care, I don't understand at all what was gained in all that.
Why should palliative chemo should be chosen over hospice. They are both comfort measure programs. Both have the same outcome and one is a heck of a lot cheaper than the other. Maybe some others can shed some light on these choices.
I can think of several thousand reasons or however many $$$ the Oncologist charged. See my "Why I Hate Oncologists" post of June 9th.
ReplyDeleteI work in a cancer specialty hospital, and I'm a nurse, but I'm pretty sure the docs and such would be pushing for hospice. A lot depends on the family though, of course.
ReplyDeleteThe oncologist goes down to the morgue to find his patient to give one last dose of chemo. He pulls open the drawer and, instead of the corpse, is a sign....."gone to dialysis".
ReplyDeleteAs long as money is to be made by "procedurizing", the boundries of medical ethics will continue to be stretched, moved, blurred, or destroyed.
Proceduralists should be salaried. That way, all of these "invasions" will be done for the right reasons, not to feed the volume machine.
Disclaimer: I am a 25 year Hodkgin's survivor, so I know both sides of the bedside. (I have also endured over 35 operations/invasive procedures in my 40 years of living.)
OK - an oldies but a goodie:
ReplyDeleteWhy do they out nails on coffins? To keep the oncologists out! BadaBing!
We had a discussion about this recently at work where we have a quorum of parental caretakers.
ReplyDeleteThere is a feeling that hospice arrives with their "palliative care" pharmacy and your loved one floats off in a haze of narcotics in pretty short order.
The caretakers feel like they hasten death with their drugs. If someone is receiving palliative chemo then isn't that (in theory) supposed to be relieving symptoms without actually going for a cure?
Yes, narcotics are cheaper than chemo drugs but some in my not-random sample of co-workers aren't comfortable doping Mom/Dad into the next world.
Anonymous 10;10
ReplyDeleteFrom my point of view, I will gladly take the "palliative care" from the hospice and float off. What on earth is the purpose of prolonging a life with no quality of life? It appears people are being kept alive for the gratification of their caretakers with little thought to what the patient is experiencing as far as pain, discomfort, etc. just to prolong life--to what purpose??
We had a pt w/ stage IV cancer w/ lung and bone mets on palliative chemo and s/p XRT who developed symptomatic constrictive pericarditis.
ReplyDeleteOne of the cardiology attendings actually considered sending the pt for pericardial stripping. I told him he was nuts. In a healthy pt the morbidity/mortality of that surgery can be 10-15%.
In a pt w/ lung mets and recent XRT I'd bet it would approach 100%.
The team got a heme-onc consult re: life expectancy. The fellow said the pt's prognosis was greater than 6 mos, perhaps a year, therefore tx for the constrictive pericarditis was indicated.
The surgeon declined to consider surgery.
CardioNP
Well, gee, if the oncologist doesn't give this poor patient chemo, what can he charge him for?
ReplyDeleteThough you bring up good points your story is incomplete:
ReplyDelete1: What is the patient's performance status. Is it less than 2 (most likely not, though we don't know)?
2: Has the patient recieved chemotherapy yet? Small cell is EXTREMEMLY sensitive to many chemotherapy agents. yes it comes back like gang-busters but it may buy 6 months to one year (or less) of quality life.
3: Though the patient states that the no treatment option was never discussed, did you discuss this response with oncology? Often what the patient states and what the doc states ocurred are very different.
4: re: "There's something you don't see every day".
Exactly, because most of the reasonable onc docs address this issue without EVER getting hospitalists involved.
5: re: "I can't think of a single reason, medically, why palliative chemo should be chosen over hospice. They are both comfort measure programs. Both have the same outcome and one is a heck of a lot cheaper than the other. Maybe some others can shed some light. "
Most hospice programs in this country specifically FORBID palliative chemo in the setting of hospice. Personally I think this rule is archaic. You can't give a hospice patient a little comfort and time with a palliative chemo that can cause minimal side effects (there is chemo and then there is chemo)?
6: To all of the oncdoc-haters out there. The simple fact is onc docs are no longer allowed to mark up drugs as ruled by medicare a few years ago and I agree with this ruling for ethical reasons (yet medicare STILL does not adequately reimburse for onc nursing, among the most highly specialized and expensive nursing care out there). So your statements about making $$$ off of giving chemo shows just how little you know about the present situation
7: Onc docs come in many flavors, personally I cringe when I see someone treated by an overally aggressive onc doc when they rightfully need hospice. I also cringe when I see PCP's, NP's, hospitalists counsel patients with cancer towards hospice when they have no clear understanding of the life expectency that patient has or treatment options. Personally, I almost never consult hospital docs because of their lack of knowledge on the subject of cancer treatment options and the time it takes undoing some of the damge done from those previous consults (I was a hospital doc long before the word "hospitalist" was coined happy so I can practice hospital medicine quite well).
I want to second the comments of anon 0135. The decision to give treatment in oncology is made using a host of factors including (obviously) the stage and type of malignancy, the performance status of the patient, whether the patient has received treament prior, and the preferences of the patient. The data for metastatic small cell are that in a patient with PS 2 the average survival without any treatment is 6-8 weeks and with treatment (usually 4 cycles of chemo - generic drugs and not terribly expensive)the average survival is 6-8 months. This is a fairly big difference esp. since the data are that quality of life is better on chemotherapy.
ReplyDeleteI also want to second the issue of profit on chemotherapy. Essentially after the MMA of 2003 which radically changed the way Part B drug are reimbursed, most oncologists break even for Medicare patients. If the patient doesn't have a secondary insurance and doesn't pay their 20% coinsurance then the oncologist loses 20% of the cost of the drug. Those of you who think that these desicions are driven by dollars should become educated on the issue before accusing an entire field of giving toxic, dangerous drugs to patients for purely profit motive. I would be happy to discuss these issue for those of you who are foisting these falsehoods.
from the point of view of a caregiver for my spouse (esophagus cancer; 4 rounds of EOX, Ivor lewis surgery, 3 rounds of cisplatin & irinoteecan,) who one year after all that chemo/surgery/chemo got the diagnosis of mets to liver,(8 spots) both lungs (1 spot each) and a lymph node by the aorta and was treated with one round of cisplatin & taxol which put him in the hospital for 6 days, home now ...
ReplyDeleteseems like the hospitalist was the realistic helper providing balanced info about options; the palliative care team, to me, felt like vultures who were eager to assign him to home health care, acted like he was on death's door and have already begun to prescribe pain meds when he continues to say he's in "no pain"... last time he was asked (I think he felt beleagured) he replied "not that I'm aware of" and the palliative team nurse wrote "pt denies pain"... we're aware that he's terminal, he feels crappy now, we have no idea (nor can we get any guesses) how much time he has, but we (perhaps foolishly) still expect he will recover from the affects of the chemo and have some quality time left; yet the palliative team doc told me to be ready to DNR because if they put him on a breathing machine he would never come off! Hospitalist when asked, said, he believed differently ...
so I'm ranting against all the alarmists who want us to just throw in the towel. We know the day will come but we really don't think it is now.
We will be asking the oncologist about alternative chemo that might buy time without killing him in the process; and then he'll choose with the best info available to him. It just seems that there are some people who are in a rush to death!
thanks for the space to rant!
I am the Daughter in law of a newly diagnosed 78 year old man with NSCLC with mets to the hip, windpipe and chest wall. I will be more than willing to take palliative chemo if it means the windpiipe isnt blocked completely by the cancer..as it is almost already. I believe any comfort available should be tried. Am I nuts to think chemo may shrink what is about to suffocate him to death? Please anyone with information enlighten me.
ReplyDelete