Morning Report

1. July 5th, 2012 Disha Kumar Dr. Curlin Morning Report Please remember to swipe in! Response Ware Login session: A700

2. MKSAP • A 63-year-old man is evaluated for slowly progressive mental status changes that have occurred over the past few weeks. The patient has a glioblastoma multiforme, with evidence of tumor enlargement and surrounding edema confirmed by head CT scan. Although he is conversant, the patient does not seem to understand the risks and benefits associated with the suggested therapeutic regimen of radiation and corticosteroid therapy and cannot provide consent for such treatment; however, he and his wife are agreeable to the physician's recommendation that this therapy be administered. The patient has not completed a formal advance directive, but his wife has accompanied him to every office visit and participated in previous discussions of diagnostic and therapeutic options.

3. MKSAP • Which of the following is the most appropriate next step in management? • A. Initiate radiation and corticosteroid therapy immediately • B. Withhold treatment pending results of psychiatric evaluation • C. Initiate guardianship proceedings • D. Seek consent from his wife before proceeding with treatment

4. Please make your selection... • Initiate radiation and corticosteroid therapy immediately • Withhold treatment pending results of psychiatric evaluation • Initiate guardianship proceedings • Seek consent from wife before proceeding with treatment

5. MKSAP • An assessment of decision-making capacity involves ascertaining whether patients understand their medical situation and the risks and benefits associated with each treatment option in addition to determining whether they are able to make and communicate decisions that reflect their values. In this case, it would be appropriate to seek the consent of the patient's wife as surrogate and then initiate treatment considering the patient's inability to understand the risks and benefits of therapy and the couple's prior assent to follow the physician's recommendation. Psychiatric consultation may be helpful when the assessment of decision-making capacity is complicated by mental illness, such as depression or psychosis, but is not generally required. Seeking a court-appointed guardian is unnecessary when there is an obvious and undisputed surrogate decision-maker, such as a spouse or adult child, and when there is no plausible disagreement about whether the proposed treatment is in the patient's best interests. Finally, withholding treatment pending legal proceedings or psychiatric evaluation would result in a delay that could potentially be harmful to the patient.

6. Chief Complaint • 27-year-old male with metastatic testicular cancer, presenting as outside hospital transfer to UCMC MICU with severe abdominal pain and distension

7. HPI • Abdominal pain and distention started 5 days prior to UCMC MICU transfer • Constipation, nausea, vomiting • Decreased PO intake • ROS: + Fatigue, nausea, vomiting, abdominal pain and distention, constipation, weakness, anxiety - Fevers, chills, chest pain, shortness of breath, diarrhea

8. Medical History PMH • Metastatic testicular cancer; mixed germ cell type • Ascites s/p large volume paracentesis (5.5L) and peritoneal drain placement • Caval thrombus • Bilateral lower extremity DVT’s • Anxiety, panic attacks PSH • Right-sided orchiectomy • Post-chemotherapy bilateral retroperitoneal lymph node dissection • Resection of IVC due to tumor and clot burden • Patch angioplasty of aorta • Resection of duodenum with duodenojejunostomy • Resection of LUQ mass • Bilateral ureterolysis

9. Medical History • Medications • Diphenhydramine 50mg PO q6h prn • Enoxaparin 80mg SQ BID • Fentanyl 25mcg/hr transdermal patch • Gabapentin 300mg PO qhs • Oxycodone 5-10 mg PO q4h prn • Lorazepam 1mg PO q6h prn • Docusate 100mg PO BID • Allergies • Penicillin • Hydrocodone • Social History • Lives with parents • Worked at jewelry store prior to medical complications • Denies tobacco, illicits • Occasional EtOH • Family history • Non-contributory

10. Oncologic History • 2009: Right-sided testicular mass, diagnosed by ultrasound • Patient elected to pursue alternative therapies and chiropractic care due to anxiety concerning surgical/medical therapy • Nov, 2011: Left-sided deep abdominal pain • Abdominal CT scan: 20cm retroperitoneal mass displacing aorta and vena cava, inseparable from the bowel and associated with partial SBO • Right orchiectomy revealed 8cm mixed germ cell tumor with extensive necrosis and focal vascular and lymphatic invasion • Chest CT and brain MRI negative for metastatic involvement

11. Oncologic History Continued • Patient underwent 4 cycles of standard bleomycin, etoposide, and cisplatin at OSH, completed in February, 2012 • CT scan: Right axillary and mediastinal lymphadenopathy with 9cm retroperitoneal mass encasing IVC and aorta; extensive thombosis in IVC and bilateral iliac systems • Underwent surgical procedures listed in Past Surgical History • Last set of tumor markers, which were previously elevated had normalized in March after surgery

12. Physical Exam • T 36.3; HR 117; BP 112/73; RR 20, O2 sat 96% RA • General: Cachectic-appearing, pale • HEENT: dry mucous membranes, PERRLA, neck supple • CV: Tachycardic, regular rhythm, normal S1/S2, no murmurs/rubs/gallops, intact distal pulses • Pulm: Normal respiratory effort, fine bibasilar crackles; no wheezes • Abd: Diffusely tender to palpation, greatest in LUQ; distended; firm; no rebound/guarding; absent bowel sounds; no peritoneal signs • MSK: Normal ROM, bilateral 2+ LE edema • Neuro: AAOx3, no focal deficits • Psych: Normal mood and affect

13. 8.4 138 100 18 95 2.0 4.4 19 1.1 4.2 AG 19 6.3 3.2 6.8 0.5 0.2/0.3 5.6 289 45 14 22.1 158 11.7 80.1 Initial Labs Ketones: 3.50 Lactate: 2.2 Tumor Markers: • - LDH: 3627 (prev normal) • B-HCG: 5070.0 (prev < 2.6) • Serum AFP: 23 Factor levels: - Fac 5: 75 (nl) - Fac 8: 326 (inc) - Fac 7: 4 (low) • OSH Labs: • - INR: 4.77 • Hgb: 8.5 --> 9.4 (7 hours later)

14. Refresher on Testicular Ca. Tumor Markers

15. Chest X-Ray on Admission

16. EKG

17. Outside Hospital CT – Day 1 • 1. Development of severe, extensive abdominal and pelvic carcinomatosis and multiple loculated ascitic fluid collections. • 2. Proximal small bowel obstruction with dilatation of the duodenum, stomach and distal esophagus. Separate small bowel obstruction involving the midportion of the small bowel in the central abdomen. In both cases, tumor is the cause. • 3. Mild bilateral hydronephrosis secondary to tumor. • 4. Left external iliac and common femoral vein thrombosis

18. OSH Course • Patient presented to OSH with severe abdominal pain, distension, nausea, vomiting, constipation • Diagnosed with partial small bowel obstruction • Treatment: IV fluids, NG to suction, and pantoprazole drip • Bright red blood per NG tube after placement that quickly became brown; NG secretions hemoccult positive • Patient became progressively hypoxic after receiving several doses of Dilaudid and vomited • Treated for aspiration pneumonia with levofloxacin 750mg IV and clindamycin 600mg IV

19. MICU Course • Patient was treated medically for SBO • GI bleed resolved; likely due to NG trauma or Mallory-Weiss tear • Anticoagulation initiated for bilateral DVT’s • Elevated INR attributed to likely malnutrition/coumadin and levofloxacin administration at OSH • Salvage chemotherapy initiated with paclitaxel, ifosfamide, and cisplatin

20. Goals of Care… • Patient indicated to oncology team soon after admission that he wished his mother to be primary decision maker, and that he preferred not to be involved in treatment details due to extreme anxiety • Patient remained full code

21. MICU Course • Hospital day 2: Patient was emergently intubated for worsening hypoxic respiratory failure and after 11 days of failed extubation proceeded to tracheostomy placement • Concern for ARDS vs pneumonia vs pneumonitis from bleomycin toxicity • Patient required high levels of FiO2 • Patient diuresed aggressively due to worsening chest x-ray, with slight improvement • Hospital day 18: NO was initiated due to continued hypoxia on toxic FiO2 • Patient unable to tolerate weaning of FiO2 and NO

22. Chest X-ray – Day 18

23. While patient was intubated and after tracheostomy was placed, sedation was lifted and patient was appropriately alert and following commands • Patient’s mother refused further staging CT scans due to fear of exacerbating malignancy, but wanted all other medical interventions • Patient’s mother also refused any conversations regarding his prognosis in the room due to his anxiety • Patient’s mother wanted him to be transferred to another hospital

24. Patient indicated to nursing staff and MICU team to “shoot him” and “let him die” • Psychiatry was consulted for management of patient’s anxiety, insomnia, and suicidal ideations • Patient was not actively suicidal • Patient deemed to have decisional capacity

25. Ethical Dilemma • Do you respect the patient’s and/or his mother’s wishes? • Are we obligated to inform the patient of his prognosis since he is competent and decisional, despite his mother’s wishes? • What were the obligations of the alternative medicine specialists and initial diagnosing physicians regarding care?

26. 4 Ethical Principles • Beneficence • Nonmaleficence • Respect for autonomy • Justice • Distributive justice • Rights-based justice • Legal justice

27. 4 Boxes Model Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. McGraw- Hill, 2010.

28. Medical Indications • The facts about a patient’s condition that indicate which forms of diagnostic, therapeutic, or educational interventions are appropriate • Beneficence and nonmaleficence • Benefit-risk ratio • How can this lead to the most optimal recommendation about appropriate action?

29. Patient Preferences • Has the patient been informed of benefits and risks, understood the information, and given voluntary consent? • Is the patient mentally capable and legally competent? • Who is the appropriate surrogate to make decisions for the incapacitated patient? • Patients have the right to information about themselves; they also have the right to refuse information

30. Medical Futility • “Medically ineffective or nonbeneficial treatment” • Nonmaleficence - Alleviating treatment burden on the patient • Who decides? The physician or the patient vs. surrogate? • How should disagreements between patients/surrogates and the medical team regarding futility be resolved?

31. The Terminally Ill or Dying Patient • Terminal - 6 months or less to live from a progressive disease despite appropriate treatment • Due to progressive and irreversible disease, patient preferences and quality of life discussions become imperative • Physicians have the moral right to withdraw from a case if he/she has reached the honest judgment of futility

32. Decisional Capacity • Specific acts of comprehending, evaluating, and choosing among realistic treatment options • Refusal of treatment should not be conisdered a sign of incapacity • Exception: Depressed patients can meet criteria for adequate decision making capacity but preferences may be clouded by mood disorder --> Involve pscyhiatry or seek surrogate involvement • Assessment of decision-making capacity: MacArthur Competence Tool • 22-item interview for assessment of adjudicative competence • Standardizes three competence-based abilities: understanding, reasoning, and appreciation Grisso T, Appelbaum P. MacArthur Competence Assessment Tool for Treatment. Sarasota, FL: Professional Resource Press; 2001.

33. Decisional Capacity: Bedside Assessment Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med 2007; 357:1834.

34. Are surrogates accurate in predicting what patients want? • Archives of Internal Medicine 2006: systematic review of 16 studies that included 2500 surrogate-patient pairs • Surrogates were accurate 68% of the time; accuracy assessed by health state and intervention • Surrogates were more accurate than physicians • Surrogate’s relationship to the patient did not correlate with predictive accuracy Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006; 166:493.

35. Surrogate Accuracy Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006; 166:493.

36. Back to our patient… • Was our patient’s mother acting in his best interest and fulfilling his wishes? • Did the patient have suicidal ideations due to his depression or was he expressing his wishes to withdraw care?

37. Hospital Course: Day 23 • The patient had worsening respiratory distress, requiring 100% FiO2 and increased NO at 33ppm. • The patient continued to state that he wanted to die. • At this point, his mother stated that she no longer wanted him to be in pain and requested DNR status so that he could die in peace. • The patient passed 12 hours after with his family at the bedside

38. Take-Home Points • As a medical team, we are obligated to be honest with a patient regarding his/her health status • The patient has the right to refuse information and decision-making • If in doubt about patient’s decisional capacity vs depression and suicidal ideations, involve consultants. • Complete bedside assessment of decisional capacity.

39. References • Appelbaum PS. Clinical Practice. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357:1834. • Grisso T, Appelbaum P. MacArthur Competence Assessment Tool for Treatment. Sarasota, FL: Professional Resource Press; 2001. • Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. McGraw- Hill, 2010. • Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006; 166:493.

40. Chemotoxicities: Bleomycin • Toxicities: interstitial pulmonary fibrosis • Less common: organizing pneumonia and hypersensitivity pneumonitis • Pathogenesis: oxidative damage and deactivation of enzyme bleomycin hydrolase • Less likely in our patient due to bleomycin administration 6 months prior

41. Chemotoxicities: TIP • Paclitaxel, ifosfamide, cisplatin • Hemorrhagic cystitis, cytopenias, infection, mental status changes, neuropathy, electrolyte wasting, ototoxicity • Patient experienced neurotoxicity secondary to ifosfamide; reversed with methylene blue