Your patient has terminal metastatic cancer. In his record, you find a Physician Order for Life-Sustaining Treatment (POLST) form that clearly documents his wishes for symptomatic treatment only: Allow a natural death; do not intubate; do not perform CPR. However, he isn’t enrolled in hospice because he’s still receiving oral chemotherapy. On exam in the emergency department, he’s in extremis, and so is his family. You’re worried he may be dying, but he isn’t going gently into that good night.

What’s your approach?

DEFINING THE EMERGENCY

First, you need to obtain more information from the family. The patient has been relatively functional until today, still walking with assistance and eating, but not a lot. Yesterday, he complained of mild nausea, but this morning, there was an acute change where his mentation was altered and he was unable to ambulate.

But are there medical emergencies at the end of life?

It turns out that there are. Antiquated thinking is that “do not resuscitate” (DNR) equals “do not treat.” This has changed significantly.

Today, there’s wide acceptance of palliative care and its aggressive symptom management, especially at the end of life. We’ll highlight four cancer emergencies that need to be recognized and managed by emergency physicians: 1) spinal cord compression, 2) pathological fracture, 3) superior vena cava syndrome, and 4) hypercalcemia of malignancy.

Spinal Cord Compression
Spinal cord compression (SCC) is most common in metastatic bone cancer. The first symptom is pain, followed by weakness of the extremities involved. The compression is most often from edema or tumor compressing on the dural sac. The gold standard for diagnosis is MRI, but in the setting of severe pain, it’s often difficult for the patient to tolerate this test because of positioning and time. For initial assessment and disposition planning, CT can give you the answers you need more quickly.

There’s a subset of end-of-life patients who will benefit from surgery:

• if they have a prognosis of three months or more
• if the paralysis has lasted fewer than 48 hours
• if there is non-radiosensitive cancer
• if there is an isolated area of SCC

In these patients, the benefits of restoring functional status may outweigh the risk of surgery. For patients who wouldn’t benefit from surgery, another treatment option is radiation therapy (RT). A single dose of RT has been shown to alleviate pain and possibly restore function. Remember to aggressively treat your patient’s pain with parenteral opioids while obtaining your diagnostics and formulating an appropriate treatment plan. With intervention, SCC patients can ideally expect an approximate three-month survival with improved pain and weakness. Without treatment, the general prognosis is one-month survival with limited quality of life.

Pathological Fractures
Along the same lines as SCC, these fractures cause debility and suffering at the end of life. Diagnosis with plain films is usually adequate. Surgical intervention may be indicated, using the same indications as with SCC. Success of surgical interventions is most impacted by the patient’s functional status prior to the fracture.

Superior Vena Cava Syndrome
Superior vena cava syndrome (SVCS) is seen primarily in lung cancer when the mass is in the right upper lobe. This mass, or the associated lymphadenopathy, obstructs the venous return through the superior vena cava into the right atrium. This leads to engorgement of veins in the upper torso, arm, face, brain, and larynx. Clinically, the patient may present with swelling of the face and neck, especially when lying down (due to increased compression of the obstructed vessel). The presentation can be as significant as altered mental status from brain edema or stridor from laryngeal edema compromising the airway.

Definitive diagnosis of SVCS requires a chest CT with contrast. Endovascular stenting is now the treatment of choice. Other options include radiotherapy or chemotherapy, depending on the sensitivity of the tumor.

Treatment of SVCS improves a patient’s quality of life and extends survival as much as six months, depending on the tumor type. Treatment of this syndrome requires a high index of suspicion on the physician’s part because it can significantly alter a patient’s overall prognosis.

Hypercalcemia of Malignancy
Lastly, a relatively common condition that arises in cancer patients is hypercalcemia of malignancy (HCM), with the incidence being as high as one in five patients. This is most commonly seen in breast and lung cancer and multiple myeloma.

Mild cases present with musculoskeletal pain and nonspecific gastrointestinal symptoms. More severe cases present with altered mental status, delirium, or coma. As with other electrolyte disturbances, it’s the rate of change, not necessarily the extent of change, that causes symptoms.

If your patient had a good functional status prior to this complication, treat HCM aggressively with fluids and IV bisphosphonates. These patients are usually profoundly hypovolemic and need aggressive IV hydration.

Bisphosphonates are now standard of care for the treatment of HCM. These agents’ main method of lowering calcium is blocking osteoclastic resorption. These drugs require 48 hours to lower calcium and must be given intravenously. There are two agents available in the United States: pamidronate, 60–90 mg IV over two hours, or zoledronate, 4 mg IV over 15 minutes. Both work well, although zoledronate is somewhat more efficacious—and more expensive.

The prognosis for HCM is well-established. Generally, the patient has about eight weeks to live, unless it’s a newly diagnosed cancer that’s responsive to cancer-directed therapy.

With all of these conditions, some patients and families may choose to forgo intervention and allow natural death to occur, especially if the patient’s disease status is advanced and functional status is poor. In these cases, the role of the emergency department is to help patients access hospice services either directly from the department or early in their hospitalization.

A SECOND LOOK

Now, back to the case. Is this the active dying process, or is something else going on?

The patient’s calcium is 14. He’s a patient who would benefit from treatment for his symptom burden, as his functional status was good up until this incident. He’s given 2 L bolus of normal saline, then started on maintenance IVF and given 60 mg IV pamidronate over two hours.

His delirium improves over the next few days, and he is able to go home. During his stay, goals of care are revisited with the patient and family, as his prognosis is now approximately eight weeks. Hospice is introduced and accepted by the patient.

Identification of these cancer-related conditions and their prognostic significance empowers the emergency department and your patients to make the most appropriate health care­–related decisions. End of life is difficult enough without an emergency added in.

Dr. Aberger is core faculty, emergency medicine/palliative medicine, for St. Joseph’s Regional Medical Center in Paterson, New Jersey. She is also chair for ACEP’s Palliative Medicine Section.

Dr. Fetzer is palliative care medical director at Rainbow Hospice and Palliative Care in Illinois.

Dr. Goett is assistant professor of emergency medicine and assistant director for advanced illness and bioethics at Rutgers New Jersey Medical School.

Dr. Rosenberg is chairman of emergency medicine, chief of population health, and associate professor clinical emergency medicine for St Joseph’s Healthcare System in New Jersey. He also serves on ACEP’s Board of Directors.