Case Discussions Challenges in End of Life

Care15/11/14

MRS B

Visit requestMon Afternoon (temp resident)

From daughter: Brought Mum to stay with me

Has Renal cancer Tired/SleepyNot Eating/drinking Just not herself

MRS B History from daughter

Age 77 , Temp Resident RENAL CANCER, LUNG METS

Diagnosed 8/12. Palliative Rx , 12/12 prognosis PMH

Hypothyroid Medication

Levothyroxine, Oxycontin/Oxynorm Allerg: Dexamthazone

History and exam Mrs B

Feeling generally unwell  Hardly eating/drinking/ no nausea Left rib pain few weeks Aware prognosis- Preferred Place of

Care = Hospice Pale, looks dry, bit confused Obs normal, abd mass A/E chest,

urine NAD

Discussion with Mrs B and daughter

Daughter strugglingMrs B will consider

admission to Hospice but nowhere else

BUT NO FEMALE BEDS IN HOSPICE

WHAT DO YOU DO NOW?

Discussion

Differential diagnosisPatient’s wishes Carer’s wishes

WHAT HAPPENED NEXT?

Urgent bloods requested (done next day)

Referred to ERT Next day

Increased confusion and reduced mobility

 Still no Hospice bed available

WHAT NEXT ?

Patient Admitted to hospital Calcium 3.34 (2.20-2.60) Albumin 32 (35-60) ALP 245 (30-130) Bilirubin 9 (<21) ALT 7 (< 35) GGT 62 (<35) CRP 38 (<5)  Urea 9.3 (2.5-7.8) Creat 90 (50-130) Egfr 47 (>60)  Hb 94 (118-148) WBC 25.6 (3.5-11) NEUTS 22 (2.0-7.5)

Then bloods phoned through

Other tests in Hospital

CT Head – normal  CT Chest/Abdomen/Pelvis –

Increase in renal mass and pulmonary metastases

 MRI Spinal Cord-No spinal cord compressionEvidence of rib invasion from

metastases  Urine/ Blood Cultures – negative

TREATMENT:

IV Fluids IV Bisphosphontes

Confusion settledMobility improvedDischarged to own home.