Mr L was a 56-year-old previously healthy businessman. He presented with progressive back pain in April 2005. Vertebral biopsy showed poorly differentiated non–small cell (squamous cell) lung cancer. His vertebral metastases and multiple asymptomatic brain metastases were treated with dexamethasone and radiation therapy.
After discussing prognosis and options with his oncologist, Dr O, he received chemotherapy with weekly gemcitabine and carboplatin. He tolerated treatment well, and for 4 months during this period his cancer did not grow. When the disease progressed, he switched to erlotinib orally. This prevented further cancer growth for almost 6 months, during which time he was asymptomatic, except for a mild rash and diarrhea. For a few months, he was able to travel and lead a normal life. However, in January 2006, Mr L’s cancer again progressed. His chemotherapy was switched to pemetrexed but the tumor continued to grow.
Mr L developed diplopia in February 2006, and meningeal carcinomatosis was confirmed in March 2006 when magnetic resonance imaging of the brain showed enhancement of the fifth, seventh, and eighth cranial nerves. In the few days Mr L took to discuss his care with his medical student son, he progressed from manageable double vision to needing a wheelchair and becoming incontinent. An Ommaya reservoir was placed, and Dr O started the patient on twice weekly intrathecal methotrexate. He improved slightly, then remained stable for 2 months, enough to return to work part time and to travel a bit. Soon progression of the leptomeningeal disease resulted in additional cranial neuropathies. The intrathecal therapy was changed to liposomal cytarabine. Mr L continued to want active therapy; he attempted to enter a clinical trial for an investigational central nervous system chemotherapeutic treatment but was not accepted due to his general debility.
Over the month prior to hospital admission, Mr L had a rapid decline with less appetite and reduced ability to walk. After several falls, he required a wheelchair for mobility. In July 2006, he was admitted to the hospital for aspiration pneumonia and hypoxemia. At the time of admission, Mr L was a “full code” and had appointed his wife as durable power of attorney for health care decisions. The patient and family had been considering hospice, as suggested by the oncologist, and had been visited at home by a hospice intake worker. However, the patient wanted to continue fighting the disease instead of entering hospice.
On examination, Mr L was a chronically ill–appearing man whose breathing was aided by nasal oxygen and who sat on a bedside “neuro” chair. He had a fourth cranial nerve palsy and disconjugate gaze, facial droop, hoarse voice, absent gag reflex, and coarse breath sounds. Chest x-ray showed multiple pulmonary nodules and a new patchy left lower-lobe infiltrate.
The medical house staff called a palliative care specialist, Dr A, who noted that the patient was receiving a dose of intrathecal liposomal cytarabine during his initial visit. Dr A discussed the patient with Dr O, who now estimated that the patient had “only a month to live.” Dr A estimated a prognosis that could be as short as 2 weeks.
The palliative care team initially conferred with the patient’s son and sister, outlined the likely prognosis, advised them to proceed with hospice enrollment, and outlined the requirement for a do-not-attempt resuscitation and do not intubate order for this hospice. After this meeting, all acknowledged that this was the end of beneficial palliative chemotherapy, which his oncologist was now no longer recommending. The family accepted these plans. Dr A then met Mr L and his wife, who agreed to these recommendations, and he met with the executor of the patient’s estate whom he urged to immediately complete a durable power of attorney for legal and financial transactions. Later, Dr A met with Mrs L and 2 sons to answer their questions (eg, likely time course, signs of impending death, eating for pleasure rather than nutrition, how to inform relatives at a distance), then talked with the hospice nurse to begin hospice enrollment. Finally, at Mrs L’s request, Dr A spoke with the patient’s mother and brother in England, who were displeased with the plan for hospice enrollment.
Mr L was transferred to his home with hospice care, where he remained alert and interactive for several days. On the sixth day at home, Mr L died peacefully with his wife and his children at his side and with his favorite music playing, some 14 months after the initial diagnosis. His mother and brother flew in from abroad but arrived only after Mr L had died.
Mrs L, Dr A, and Dr O were interviewed by a Perspectives editor in August and September 2006, 2 months after Mr L’s death.