Mrs H.
Mrs H. is a 78-year-old woman with recurrence of breast adenocarcinoma. The cancer was initially treated with bilateral mastectomy, radiation, and chemotherapy 2 years ago. Mrs H. tolerated the treatments well. She was able to resume her normal activities and describes the treatments as "not that bad." After recurrent hospitalizations several months ago for pain and symptoms related to the cancer recurrence and other chronic medical conditions, Mrs H. was admitted to a nursing facility for subacute rehabilitation. The initial plan of care was to control her pain and get her strong enough to receive additional radiation and chemotherapy. However, Mrs H. has now lived in a nursing home for 4 months with little overall improvement in her functional status. Today, the nursing home staff transferred Mrs H. to the emergency room for worsening pain in her upper back and chest. Diagnostic tests ruled out an acute cardiac event, but because of her uncontrolled pain, rated as 10 on a scale of 0 to 10, and need for symptom management, she was admitted to the hospital with a diagnosis of "persistent chest pain—noncardiac origin."
Scans during hospitalization revealed advancing breast cancer, now stage 4 with distant metastasis to the liver, ribs, and lungs. Past pain medication regimens were reviewed and included long-acting oxycodone with immediate-release oxycodone for breakthrough pain, intravenous hydromorphone when hospitalized (which was very effective, but not feasible for continued use in a nursing home), and a 3-day trial of methadone. Methadone was discontinued by the nursing home's medical director because of drowsiness. Sustained-release oxycodone initially worked well, but after several months, it was no longer was effective at controlling her pain.
A palliative care consult was requested for symptom management—particularly assessment and management of what appeared to be refractory pain and goals-of-care clarification. During the palliative care consult, Mrs H. made little eye contact and would not discuss her diagnosis or prognosis at length. However, she did acknowledge concerns about her constant pain and recurrence of breast cancer. She also revealed that her husband of 50 years died suddenly 7 months ago, and she had not told anyone, not even the nursing home staff. She has no children, and her closest relative, a sister, lives several hundred miles away.