The patient is a 90 year-old
man, homebound with a dementia. His 87
year-old wife is a steadfast, loving and loyal caregiver. His dermatologist has made house calls for
the past four months.
There are non-melanoma skin
cancers on the left cheek and mid upper
lip. The former lesion has increased
from 1.3 to 1.5 mm in diameter and the the lip lesion has increased from 1.8 to
2.2 mm in diameter in the past two months.
Both are somewhat inflammatory and crusted. He picks on the lip lesion,
but because of his dementia he can not articulate what it is that bothers him.
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| 7.28/15 |
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| March 2016 |
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| 6.28.2016 |
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| 8.11.16 |
A trial of topical 5-FU plus
imiquimod may be helpful, especially for the lesion on the lip, as a palliative
procedure. The lesion on the malar
eminence which grew rapidly ~ 6 months ago and is either a squamous cell or a
keratoacanthoma) could be curetted and dessicated.
The patient can not make a
decision for himself and his wife wants to just watch these lesions. She understands that treatment is not likely
impact on his quality of life at this point and want’s to spare him the trauma or surgery.
As physicians, we feel compelled
to “do something.” Is this the right
time to “not just do something, but to sit there.”
Reference:
1. Linos E. Treatment of
nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013 Jun 10;173(11):1006-12
CONCLUSIONS AND RELEVANCE: Most
NMSCs are treated surgically, regardless of the patient's life expectancy.
Given the very low tumor recurrence rates and high mortality from causes unrelated
to NMSC in patients with limited life expectancy, clinicians should consider
whether these patients would prefer less invasive treatment strategies. PubMed. PMC Free Full Text.
2.
Knocking on Heaven’s
Door
by Katie Butler is an
honest, sobering book that describes what awaits so many elderly people and
their caregivers, who are often family members. It is relevant to how one
manages a patient such as the man described and discussed here.
I support the patient's wife. Currently it doesn't seem as if there is likely to be more benefit in doing anything more than watching.
ReplyDeleteAtleast- in this case, the wife is clear about what she wants and how she would move forward. It's far more easier for us to formulate a logical plan.
ReplyDeleteIn my experience, when the decisions has to be made by children of an elderly patient (who show up in the hospital from far away usually out of state and who has not really stayed with that person lately) they are clueless about what his baseline is, how his cognitive abilities are etc .They usually want "everything" to be done and expect miracles because they are "told" he was walking/driving/living alone just fine till last week. It's far more challenging in those moments when knowingly we are forced to do aggressive procedures that really do not enhance qualify of life.