Metastatic pancreatic cancer: Meeting palliative care needs

HC is a 73-year-old woman with pancreatic cancer. At the time of diagnosis, she also was found to have lung and liver metastases. HC is a widow and th e mother of three adult children. The patient was receiving treatment on a phase II clinical trial with continuous intravenous drug infusion (using a portable volumetric infusion pump) for 14 days every 21 days. HC had also b een on Medicare Hospice Benefit for approximately 6 weeks. HC was using oxygen at home intermittently, but recently she had reported i ncreased dyspnea on exertion to her hospice care providers. She was advised to increase the use of oxygen and to continue with her current medications and dosages of controlled-release oxycodone, 20 mg every 12 hours, with ox ycodone, 10 mg every 4 hours, as needed for breakthrough pain Although it is a 3-hour roundtrip drive from NC's home to the academic medi cal center at which her oncologist practices, she wanted to continue her ap pointments with the oncologist and oncology nurse practitioner. When NC and her boyfriend arrived at the medical center for a regularly scheduled appo intment, she was noted to be extremely short of breath despite continuous o xygen per nasal canula. Assessment by the oncologist and oncology nurse pra ctitioner revealed the presence of pleural effusion confirmed on chest x-ra y. NC was informed of these findings and was advised that a thoracentesis w as necessary for the relief of symptoms, This procedure was performed by in terventional radiology later that afternoon, at which time a permanent ches t tube was placed. HC was quite taxed after the procedure, but her dyspnea was significantly reduced. The patient agreed with the oncologist and nurse practitioner's recommendation that she stay overnight at the medical cente r rather than make the long drive home that evening. This would also allow time for teaching the patient and her boyfriend about home management of th e permanent chest tube. A call was made to the director of the hospice program who informed the nur se practitioner that the program did not have a contract for inpatient admi ssion at the medical center, although they did have a contract with the hos pital in HC's home community. The director advised the patient to disenroll from the hospice benefit, which would then allow, payment for the admissio n under the patient's Medicare Benefit Part A. The hospice director and nur se practitioner had a further discussion regarding the need for improved sy mptom management in the future, House staff responsible for admitting HC to the oncology unit requested guidance from the Palliative Care Consult Serv ice about strategies to best address this patient's needs, especially with the likelihood of discharge the next day.