In the few days Mr L took to discuss his care with his medical student son, he progressed from manageable double vision to needing a wheelchair and becoming incontinent. Mr L developed diplopia in February 2006, and meningeal carcinomatosis was confirmed in March 2006 when magnetic resonance imaging of the brain showed enhancement of the fifth, seventh, and eighth cranial nerves. His chemotherapy was switched to pemetrexed but the tumor continued to grow. However, in January 2006, Mr L’s cancer again progressed. For a few months, he was able to travel and lead a normal life. This prevented further cancer growth for almost 6 months, during which time he was asymptomatic, except for a mild rash and diarrhea. When the disease progressed, he switched to erlotinib orally. He tolerated treatment well, and for 4 months during this period his cancer did not grow. His vertebral metastases and multiple asymptomatic brain metastases were treated with dexamethasone and radiation therapy.Īfter discussing prognosis and options with his oncologist, Dr O, he received chemotherapy with weekly gemcitabine and carboplatin. Vertebral biopsy showed poorly differentiated non–small cell (squamous cell) lung cancer. He presented with progressive back pain in April 2005. Mr L was a 56-year-old previously healthy businessman. Approaches to communication about prognosis and treatment options and questions that patients may want to ask are discussed. He lived 14 months with 3 types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly communicated. We illustrate how clinicians involved in palliative care and oncology can more effectively work together with the story of Mr L, a previously healthy 56-year-old man, who wanted to survive his lung cancer at all costs. Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice.
Patients face difficult decisions about chemotherapy near the end of life.