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John is a 69-year-old man married to Mary, 68, for 43 years. They have just moved to live close to their daughter and have always had active lifestyles. They invested their retirement funds in a condominium near a golf course. John was doing well at home until about 2 months ago when he noticed shortness of breath on exertion. Mary had suffered a fall around the same time with a fracture of her hip requiring hospitalization. John as well as his family considered John's shortness of breath to be due to ongoing stress and anxiety.

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One week ago John fell on the left side of his chest, and since then his pain and shortness of breath have continued to increase and are persistent with rest. He went to the ER and was diagnosed with pulmonary emboli with a left upper lobe infiltrate with bilateral hilar and mediastinal lymphadenopathy. John was admitted for further evaluation. John, Mary, and their daughter are very optimistic about the workup and reassure themselves that everything will be fine. John was ultimately diagnosed with metastatic non-small cell lung cancer. He was very frightened and angry when he was told about the biopsy results. His family wanted to get all possible treatments done. They want to have a meeting with the oncologist to discuss the possible treatment options and plan for the future.

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1. Assuming that the chances of complete remission are very small, what is the most appropriate course of action?

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Answer

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  1. After establishing a trusting relationship, the physician should assess the patient's understanding of the illness and then gently share the information that will bring the patient's understanding closer to medical reality. Offering false reassurance is unkind and unethical. Additionally, symptom control, emotional support, and a caring presence are necessary and appropriate.

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If the patient is terminally ill but not yet psychologically ready to hear bad news, a palliative care consult will help to define the goals of care and services available.

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The palliative model of care recognizes the importance of symptom control, relief of suffering, and support for the best quality of life for patients and their families, regardless of the stage of illness or need for other therapies. Table 51-1 compares the characteristics of curative and palliative care.

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Table 51-1. Characteristics of Curative Versus Palliative Care Models

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