Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care.

Tom, a 50-year-old man with metastatic pancreatic cancer, was referred by his phase I physician to our supportive care center for symptom management. He was initially diagnosed with pancreatic cancer involving the liver approximately 6 months before this visit. He developed progressive disease despite three lines of systemic therapy, including four cycles of gemcitabine and cisplatin, three cycles of gemcitabine and vorinostat under phase I, and two cycles of fluorouracil, leucovorin, and oxaliplatin 6. His clinical course was complicated by recurrent venous thromboembolic events. Tom arrived at the supportive care clinic in a wheelchair and accompanied by his wife. He complained of right upper quadrant pain, particularly with inspiration, despite taking morphine continuous release 30 mg twice a day. He had also experienced severe fatigue, weakness, constipation, decreased appetite, and weight loss of 25 kg during the previous 5 months. Eastern Cooperative Oncology Group performance status was 4. Edmonton Symptom Assessment Scale (0 no symptom, 10 worst possible) revealed pain 8, fatigue 4, nausea 0, depression 0, anxiety 0, drowsiness 0, appetite 10, well-being 5, dyspnea 5, and sleep 5. On examination, he looked thin, was tachycardic and tachypneic, and had significant tenderness over the right upper quadrant. He was also experiencing severe weakness and had to use both hands to lift his legs to move around in bed. He lived with his wife and one son at home, but he had difficulty coping with the worsening symptoms. We adjusted his pain medications and laxatives, gave him a dose of methylnaltrexone in the clinic, recommended a home-safety evaluation, and provided supportive/expressive counseling. He expressed the desire not to receive any more cancer treatments, and we discussed the transition to hospice care so he could get more support at home. At the end of the visit, Tom said, “Oh, I wish I had seen you sooner. Why wasn’t I referred here earlier?” Tom went home with hospice care and died 10 days later.