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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Define the goals for pain management in a patient with chronic malignant pain with hospice services.

  • Define a pharmacotherapeutic pain management plan.

  • Differentiate between palliative care and hospice care.

  • Select or recommend medication options for management of nausea in a hospice setting.

  • Define the role of continuation of nutritional support and antibiotic therapy in a hospice setting.

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PATIENT PRESENTATION

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Chief Complaint

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“I have been having fevers up to 102°F and chills for two days. I have also noticed that my skin is orange in color.”

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HPI

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Jamie Park is a 48-year-old woman with a history of metastatic gastric adenocarcinoma originally diagnosed 3 years ago. At that time, she had a subtotal gastrectomy with 16 out of 16 positive lymph nodes. She received adjuvant chemoradiation with 6 months of 5-fluorouracil. Two years ago, she developed gastric outlet obstruction and underwent laparotomy with extensive lysis of adhesions and revision of the gastrojejunostomy. She had no evidence of malignancy after this surgery. Three months later, she presented with symptoms of obstruction and underwent a sigmoid colectomy with pathology, revealing metastatic gastric adenocarcinoma. She was then started on chemotherapy with epirubicin, cisplatin, and capecitabine × 6 cycles. Her chemotherapy course was complicated by neutropenia requiring significant dose reduction. After completing six cycles, she had worsening small bowel obstruction and underwent surgery, where recurrent metastases to the small intestine were found. The metastases were resected, but several other malignant peritoneal nodules were seen during surgery. Four months after the surgery, she underwent colonoscopy due to further obstruction at the level of the colon. The procedure was complicated by cecal dilatation, requiring an urgent percutaneous cecostomy. A week later, she underwent a repeat exploratory laparotomy with jejunojejunal bypass and ileosigmoid bypass. After the last surgery, the patient did not recover any intestinal function and was started on chronic TPN therapy. Four months ago, the patient underwent elective percutaneous biliary drain placement for biliary obstruction due to tumor. She was recently enrolled in supportive hospice services but continues on TPN for treatment of chronic small bowel obstruction.

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Mrs Park presents today with a 2-day history of fevers and chills, abdominal pain, and recurrent jaundice. She had been using Tylenol suppositories for the fevers at home without relief. Her abdominal pain has worsened over the past 2 days, and she currently rates the pain as 8 out of 10. This pain is not relieved by the use of as-needed oxycodone liquid.

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PMH

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  • Cholangitis

  • Gastric outlet obstruction and small bowel obstruction

  • Subtotal gastrectomy 5 years ago

  • Sigmoid colectomy 2 years ago

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FH

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  • Mother—cervical cancer

  • Maternal aunt—laryngeal cancer

  • Maternal uncle—liver cancer

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SH

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Mrs Park is ...

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