Case Discussions
Challenges in End
of Life Care
15/11/14
MRS B
Visit request
Mon Afternoon (temp resident)
 From
daughter: Brought Mum to
stay with me
 Has
Renal cancer
 Tired/Sleepy
 Not
 Just
Eating/drinking
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
struggling
 Mrs
B will consider admission to
Hospice but nowhere else
 BUT
NO FEMALE BEDS IN
HOSPICE
WHAT DO YOU
DO NOW?
Discussion
 Differential
 Patient’s
 Carer’s
diagnosis
wishes
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
Then bloods phoned through













Calcium
Albumin
ALP
Bilirubin
ALT
GGT
CRP
Urea
Creat
Egfr
Hb
WBC
NEUTS
3.34
32
245
9
7
62
38
9.3
90
47
94
25.6
22
(2.20-2.60)
(35-60)
(30-130)
(<21)
(< 35)
(<35)
(<5)
(2.5-7.8)
(50-130)
(>60)
(118-148)
(3.5-11)
(2.0-7.5)
Other tests in Hospital

CT Head – normal

CT Chest/Abdomen/Pelvis – Increase in
renal mass and pulmonary metastases

MRI Spinal Cord No
spinal cord compression
 Evidence
of rib invasion from
metastases

Urine/ Blood Cultures – negative
TREATMENT:
 IV
Fluids
 IV Bisphosphontes
 Confusion
settled
 Mobility improved
 Discharged to own home.