Admitting cancer

[hoot504]

Question for the attendings on this forum. What is your practice if in your workup you find evidence of a previously unknown malignancy? I'm not talking about a pulmonary nodule. I mean, hepatic mass, pancreatic mass, renal, whatever. The patient's workup is otherwise benign. Maybe they have some persistent pain in the associated area. Are you admitting these patients for further workup and management? DC to home? Of course it will sometimes depend on how likely you feel patient is to be lost to follow-up.

Had a recent elderly patient who presented w/ epigastric pain. Patient was post-cholecystectomy. CT demonstrated CBD and pancreatic ductal dilatation highly suspicious for mass at the head of the pancreas. My practice would be to admit this all day long. It was signed out to the next team (resident) before the imaging had returned, and eventually discharged w/ GI follow-up "for outpatient ERCP". Really?

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[BoardingDoc]

Question for the attendings on this forum. What is your practice if in your workup you find evidence of a previously unknown malignancy? I'm not talking about a pulmonary nodule. I mean, hepatic mass, pancreatic mass, renal, whatever. The patient's workup is otherwise benign. Maybe they have some persistent pain in the associated area. Are you admitting these patients for further workup and management? DC to home? Of course it will sometimes depend on how likely you feel patient is to be lost to follow-up.

Had a recent elderly patient who presented w/ epigastric pain. Patient was post-cholecystectomy. CT demonstrated CBD and pancreatic ductal dilatation highly suspicious for mass at the head of the pancreas. My practice would be to admit this all day long. It was signed out to the next team (resident) before the imaging had returned, and eventually discharged w/ GI follow-up "for outpatient ERCP". Really?

I try to find a reason to admit them because of the peace of mind that an expedited workup will bring them. That said, there isn't always a reason to do so, in which case an outpatient workup is entirely appropriate. Sounds like that was the case with your patient.

 

[bravotwozero]

I second what boarding doc says. You can really play the cancer diagnoses either way, depending on family wishes/resources available, urgency etc. If your guy was jaundiced, that would be a slam dunk admission for a biliary stent placement. Otherwise, dc home is fine too.

 

[TooMuchResearch]

I can get outpatient oncology and most other specialties within a couple days, admission doesn't really speed things up. If not acutely ill requiring admission, often home. Not always though.

 

[deleted859535]

I second what boarding doc says. You can really play the cancer diagnoses either way, depending on family wishes/resources available, urgency etc. If your guy was jaundiced, that would be a slam dunk admission for a biliary stent placement. Otherwise, dc home is fine too.

My practice mirrors this. If it medically needs admission, done. Short of that: if the patient/family needs to be at home for awhile, I go out of my way to secure short-term follow-up accordingly. If he/she wants to be admitted, I go out of my way to get them admitted even if the hospitalist pushes back since it "can be worked up outpatient."

The jerk who came to the ED with a cough for two hours can wait while I do all this. It's a new cancer diagnosis. They get my full attention and whatever they need to help initial coping and care.

 

[DrYoda]

Depends on both patient preference and the presentation. If they present acutely ill (PE, neuro-deficits, paraneoplastic syndromes, neutropeneic fever ect.) admit. If the presentation and workup is fairly benign I will offer admission, but if they'd rather go home that's fine; our local oncology group is great about seeing these patient's within the next 48 hours. That said this one of the few groups where I do actually call the consultant to ensure close follow up.

 

[shoal007]

Our oncology group won't see these patients until they have a tissue dx. It's quite frusterating. So I have to arrange biopsy and then oncology appt. Otherwise I try to admit.

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[southerndoc]

A week or two is not going to make a difference in mortality in most cancers. If there isn't another reason for admission and if the patient has an established primary care physician, then they get returned to the PCP, heme/onc, and whatever specialty is necessary. If they don't have a PCP or don't have insurance, I talk to someone from heme/onc to see if they can be seen quickly in the STAT clinic. If so, they go there (usually within a week). It meets twice/week and is pretty nice: all specialties have representatives (neurosurgery, spine surgery, GI, thoracic surgery, oncology surgery, heme/onc, radiation oncology, etc.).

Of course if the patient is totally freaking out and I feel like they would consider it totally wrong for me to send them home, then I admit them. Luckily, I never get pushback from our hospitalists.

 

[deleted547339]

If it’s not an acute leuk, it probably doesn’t need to come in. Admission can often not lead to expedited care. If the patient has no resources whatsoever, it may be helpful.

 

[Rendar5]

If significant symptoms or little ability to get outpatient management I will admit. I also don’t tusually them they have cancer unless it is ridulously a slam dunk. Rather, they have a mass that may or may not be cancer.

 

[gutonc]

I can get outpatient oncology and most other specialties within a couple days, admission doesn't really speed things up. If not acutely ill requiring admission, often home. Not always though.

Coming from the other side of the issue, I more or less agree with this approach. I would put in a plug for a phone call to your friendly local oncologist (and I recognize you don't all have one of these) to ask what s/he thinks and for help in guiding any acutely needed workup.

Here are 2 recent examples from a weekend when I was on call for my group.

1. 51M w/ worsening fatigue over months. Saw PCP on Friday who ordered labs. CBC came back at 8pm with WBC of 1.8, ANC 600, Hg 6.3 and Plts 22K. Called by PCP to go to ED, which he did on Sunday afternoon. Got 2U pRBCs but refused admission for workup because he was otherwise asymptomatic. I arranged to see him on Monday, did a bone marrow biopsy that day and had him admitted to the leukemia service a day after the biopsy result came back (which took almost a week...during which he got more RBCs and some platelets in my office). This one was a pretty easy one to workup and deal with as an outpatient.

2. 52M w/ remote h/o incompletely resected melanoma (he didn't f/u for WLE as referred) who'd been getting massage and chiropractic adjustments for back and neck pain, sent to ED after chiropractor ordered a CXR which showed diffuse osseous sclerotic lesions. Also decided to wait until Sunday afternoon to get evaluated. Got a CT chest in the ED with showed massive axillary LAD and diffuse bony lesions. ED recommended admit and hospitalist came to admit him but, since his pain was controlled, decided not to admit him and called me to get f/u set up. I saw him the same Monday as the other guy. Called a surgeon (first thing Monday morning) to arrange a biopsy of the axillary LN and ordered a PET scan. Surgeon can't get him in until that Friday and insurance won't approve the PET scan without pathology. So, what could have been a 2 day admit (PET on Monday, biopsy and home on Tuesday at the latest), f/u with me on Thursday for path/imaging review and start treatment the following Monday, now turns into See me Monday, biopsy that Friday, PET sometime the next week (hopefully), see me in 2-3 weeks when all this crap is done and then another day or 7 to get approval for whatever treatment I'm going to give him.

 

[Tenk]

If no lab abnormalities or other problems: dc with outpatient follow up. I usually call and arrange with oncology. If they don’t want to play along then I admit them to the hospitalist and blame the oncologist for being lazy. Usually hospitalist just sighs and says: fine. That’s pretty rare though.

 

[GonnaBeADoc2222]

I find that there's a lot of times a failure to thrive type component that I admit these people for. I had a guy who had symptoms for a couple months, some outpatient midlevel (who btw the patient - a pretty with it person - thought was a physician - amazing how this misrepresentation often happens) orders a CT which shows a locally invasive and metastatic process. CT was 2-3 weeks ago. Patient never informed - instead told there was an "abnormality" and "needs a biopsy." So I got to explain it. In any case, patient hadn't been eating or drinking for some days - so I admitted him for hydration, etc.

 

[engineeredout]

I think you can come up with a reason to admit these people if need be (intractable pain, symptomatic anemia, can't tolerate PO etc...) if the patient has no good support system for follow up or if they feel they need to be admitted.

From the inpatient side of things, I can say that an admit doesn't speed things up a tremendous amount. Most I've seen is pt gets a biopsy of whatever, gets dced if stable, and follow up with onc as an outpatient. Unless another specific complication, not much for an inpatient team to do acutely. That being said, I don't think you're wrong to bring these patients in if it is needed, and I am never mad to receive one of these admissions (although they're depressing)

Just please, if you're going to admit it, please tell the patient that they likely have cancer. Don't use the words "mass, lesion, finding". Just say your concern is for cancer. It gets awkward for the inpatient team when the patient doesn't know why they're being admitted.

 

[gutonc]

I think you can come up with a reason to admit these people if need be (intractable pain, symptomatic anemia, can't tolerate PO etc...) if the patient has no good support system for follow up or if they feel they need to be admitted.

From the inpatient side of things, I can say that an admit doesn't speed things up a tremendous amount. Most I've seen is pt gets a biopsy of whatever, gets dced if stable, and follow up with onc as an outpatient. Unless another specific complication, not much for an inpatient team to do acutely. That being said, I don't think you're wrong to bring these patients in if it is needed, and I am never mad to receive one of these admissions (although they're depressing)

The one way that things do get sped up in this situation is the prior auth issue as I outlined above. If you admit them, they get the biopsy, the imaging and go home to follow up in a few days (and usually meet me so they have a face to put to the name and know that someone's going to be paying attention, even though I don't have much to tell them at that moment). Outside of the ivory tower academic places, this kind of workup usually takes quite a bit longer.

Just please, if you're going to admit it, please tell the patient that they likely have cancer. Don't use the words "mass, lesion, finding". Just say your concern is for cancer. It gets awkward for the inpatient team when the patient doesn't know why they're being admitted.

On the flip side, even by the time they walk into my office a day or 12 later, and see the big sign over the front door that says "Cancer Center", they still typically don't have the slightest clue what's going on.

 

[TraumaLlamaMD]

Coming from the other side of the issue, I more or less agree with this approach. I would put in a plug for a phone call to your friendly local oncologist (and I recognize you don't all have one of these) to ask what s/he thinks and for help in guiding any acutely needed workup.

Here are 2 recent examples from a weekend when I was on call for my group.

1. 51M w/ worsening fatigue over months. Saw PCP on Friday who ordered labs. CBC came back at 8pm with WBC of 1.8, ANC 600, Hg 6.3 and Plts 22K. Called by PCP to go to ED, which he did on Sunday afternoon. Got 2U pRBCs but refused admission for workup because he was otherwise asymptomatic. I arranged to see him on Monday, did a bone marrow biopsy that day and had him admitted to the leukemia service a day after the biopsy result came back (which took almost a week...during which he got more RBCs and some platelets in my office). This one was a pretty easy one to workup and deal with as an outpatient.

2. 52M w/ remote h/o incompletely resected melanoma (he didn't f/u for WLE as referred) who'd been getting massage and chiropractic adjustments for back and neck pain, sent to ED after chiropractor ordered a CXR which showed diffuse osseous sclerotic lesions. Also decided to wait until Sunday afternoon to get evaluated. Got a CT chest in the ED with showed massive axillary LAD and diffuse bony lesions. ED recommended admit and hospitalist came to admit him but, since his pain was controlled, decided not to admit him and called me to get f/u set up. I saw him the same Monday as the other guy. Called a surgeon (first thing Monday morning) to arrange a biopsy of the axillary LN and ordered a PET scan. Surgeon can't get him in until that Friday and insurance won't approve the PET scan without pathology. So, what could have been a 2 day admit (PET on Monday, biopsy and home on Tuesday at the latest), f/u with me on Thursday for path/imaging review and start treatment the following Monday, now turns into See me Monday, biopsy that Friday, PET sometime the next week (hopefully), see me in 2-3 weeks when all this crap is done and then another day or 7 to get approval for whatever treatment I'm going to give him.

Are you able to easily arrange inpatient PET where you work? It’s almost impossible at my hospitals.

 

[gutonc]

Are you able to easily arrange inpatient PET where you work? It’s almost impossible at my hospitals.

Yes, at least at the hospital where I work. Usually takes a day to make sure they have the isotope on hand. But 2 of the 5 hospitals in our system don't have a PET scanner, so they either need to be transferred, or scanned as an outpatient anyway.

I also want to make it clear that I understand that everybody's practice environment is different and what works in my system may not work in yours.

 

[TheComebacKid]

I find it pretty easy to admit these patients and will end up admitting almost all of them. They usually present to the ED with something i.e. irretractable nausea/vomiting, dehydration, jaundice, severe abdominal pain, hemoptysis and so forth. Sure, we know the culprit and often times symptomatic management and outpatient follow-up can be arranged, but it's not hard to sell to inpatient team

At the end of the day, I leave it up to the patient and let them do whatever they feel comfortable with. I find most patients prefer admission because it offers expedited work up, and they can ask the heavy questions they have on their mind. A lot of patients we see are uninsured and the only way to guarantee they will get some sort of follow-up is admit them.

On a side note, this is easily IMO one of the hardest parts we have in our job, and something I vastly underestimated. Delivering bad news is always hard, but it's particular hard when the patient came in for a seemingly benign complaint such as "nausea and belly pain" and you have to tell them that their CT scan shows a large pancreatic lesion that is suspicious for malignancy. It seems we do this A LOT in emergency medicine, a lot more so than I expected.

Eff cancer.

 

[miacomet]

The worst problem I had with this was when I worked in rural Oregon. It was almost impossible to arrange follow up and even more impossible to transfer to the cancer center. Terrible. Where I work now the worst thing that happens is they get a call from the cancer center the next day to set things up.

 

[TooMuchResearch]

I think you can come up with a reason to admit these people if need be (intractable pain, symptomatic anemia, can't tolerate PO etc...) if the patient has no good support system for follow up or if they feel they need to be admitted.

From the inpatient side of things, I can say that an admit doesn't speed things up a tremendous amount. Most I've seen is pt gets a biopsy of whatever, gets dced if stable, and follow up with onc as an outpatient. Unless another specific complication, not much for an inpatient team to do acutely. That being said, I don't think you're wrong to bring these patients in if it is needed, and I am never mad to receive one of these admissions (although they're depressing)

Just please, if you're going to admit it, please tell the patient that they likely have cancer. Don't use the words "mass, lesion, finding". Just say your concern is for cancer. It gets awkward for the inpatient team when the patient doesn't know why they're being admitted.

I tell them it's probably cancer, unless it's mets from a known cancer, then I tell them their cancer has spread.

 

[gro2001]

Question for the attendings on this forum. What is your practice if in your workup you find evidence of a previously unknown malignancy? I'm not talking about a pulmonary nodule. I mean, hepatic mass, pancreatic mass, renal, whatever. The patient's workup is otherwise benign. Maybe they have some persistent pain in the associated area. Are you admitting these patients for further workup and management? DC to home? Of course it will sometimes depend on how likely you feel patient is to be lost to follow-up.

Had a recent elderly patient who presented w/ epigastric pain. Patient was post-cholecystectomy. CT demonstrated CBD and pancreatic ductal dilatation highly suspicious for mass at the head of the pancreas. My practice would be to admit this all day long. It was signed out to the next team (resident) before the imaging had returned, and eventually discharged w/ GI follow-up "for outpatient ERCP". Really?

I am assuming you mean the cases where there is no other obvious reason to admit other than the new suspicion of cancer. If the patient is sick, jaundiced, in immediate risk of something bad happening, obviously I would admit.

For the otherwise well patient who has a very high likelihood of having cancer based on imaging but is otherwise well, what I do highly depends on the patient and how well they fit into the system. If they are with it, insured, have a PMD, and can clearly advocate for themselves, I explain everything to them with specific instructions and discharge. However, if I suspect they have a higher likelihood of falling through the cracks due to issues like lack of insurance, language barriers, mental illness, etc then I usually admit. Obviously allowing for patient preference in either direction.

 

[NITRAS]

Our IR is strongly pushing back against inpatient biopsies. Oncology usually offers little on an inpatient basis. Unfortunately, our ED admits them and tells they they are going to get a biopsy, need chemo etc.....but I usually discharge them in the am and look like a bad guy.

That’s insurance, that’s life.

 

[DoctwoB]

From the surgeon perspective unfortunately I can just tell you that it depends. If you found a big bladder mass on CT and admit and I can squeeze it into the OR schedule or after clinic the next day it would expedite care. Sometimes that’s not the case and I have to discharge to clinic follow up. I doubt there is any difference in patient outcomes with slightly delayed management but patients often hate it because they want an answer right now, and I can’t say I blame them.

I’d say the best route is to give whatever specialist needs to see the patient a call and let them weigh in.

 

[Apollyon]

Our IR is strongly pushing back against inpatient biopsies. Oncology usually offers little on an inpatient basis. Unfortunately, our ED admits them and tells they they are going to get a biopsy, need chemo etc.....but I usually discharge them in the am and look like a bad guy.

That’s insurance, that’s life.

You need to go up the chain and have that behavior checked. If you have IR and onc, I'm guessing an academic hospital. Even so, I never EVER tell the patients what WILL be done - I tell them that it is up to the specialist, and if I say "X", and the specialist says "Y", then the pt gets confused. So I don't say "X". It's one thing to tell the pt that the hip is broken. However, I don't tell them there will be a THR, or a rod, or whatever, 'cause I ain't the one doing it.

That reminds me - my best friend is a PhD dept chair in a college of education. I was telling him about academic slugs in EM (and medicine), because they can't function in the community. As I said, "they need to live in the zoo, because they can't live in the wild". His stable of faculty are similar. As he reminds me, often, "the battles are so bloody, because the stakes are so low".

 

[NITRAS]

Yes it’s residents. It’s an ongoing conversation. They usually learn by the time they graduate, but there are a couple old time staff who don’t like to change. We are actually trying to work jointly on several things right now, mostly to reduce readmissions. Baby steps.

Cancer sux. Did I mention I don’t envy the EM docs.

 

[Birdstrike]

Nowhere more than in Emergency Medicine are we more aware at how slow, difficult and problematic, follow up can be for some patients. That makes it extra hard to meet someone for the first time, give them a sudden, unexpected and devastating diagnosis, then discharge them into an outpatient world with all of the inherent difficulties in finding timely follow up with a specialist, especially by a patient that's emotionally reeling from a terrible diagnosis, with countless questions about to start streaming into their head after the shock wears off.

In theory, admitting someone doesn't necessarily speed up the work up and treatment of most cancers which are handled in the outpatient setting (so the internists always seem to say). Still, it's a terribly difficult thing to tell someone you've just met they have cancer (especially if it's advanced) and then send them home to leave them hanging with nothing but a diagnosis and google, while you turn around and admit multiple people to the hospital who don't necessarily have anything life threatening, most if not all you know with near certainty will outlive the person you're being told to send home.

It's a call I've made many times, to hospitalists, "Just diagnosed Mr. ______ with ____(insert hellish, unexpected and advanced cancer diagnosis)____. Man, what a shame. Although he's stable right at the moment, I can't see sending him home after giving him this news."

Hospitalist, "Well, you know as well as I do, he needs to see heme/onc in the office and admitting him isn't going to speed anything up, right? You know we don't admit these when we find this stuff in the office, right?"

"Well, I know, but geez...."

It's a very difficult thing, that seems emotionally surreal and like it absolutely needs to happen a different way, but often doesn't. Emotionally if feels like if you are newly diagnosed with a serious cancer, that ought to buy you at least the option of admission, considering all the BS that often gets admitted for absurd reasons. But I know a lot of hospitalists and oncologists don't always feel it speeds up the time to treatment. That being said, if someone can truly get treated quicker in the outpatient setting, then by all means get them treated as quick as possible. Having seen so many patients get lost to follow up, over the years, I'm always skeptical when I hear that promise.

 

[GonnaBeADoc2222]

Nowhere more than in Emergency Medicine are we more aware at how slow, difficult and problematic, follow up can be for some patients. That makes it extra hard to meet someone for the first time, give them a sudden, unexpected and devastating diagnosis, then discharge them into an outpatient world with all of the inherent difficulties in finding timely follow up with a specialist, especially by a patient that's emotionally reeling from a terrible diagnosis, with countless questions about to start streaming into their head after the shock wears off.

In theory, admitting someone doesn't necessarily speed up the work up and treatment of most cancers which are handled in the outpatient setting (so the internists always seem to say). Still, it's a terribly difficult thing to tell someone you've just met they have cancer (especially if it's advanced) and then send them home to leave them hanging with nothing but a diagnosis and google, while you turn around and admit multiple people to the hospital who don't necessarily have anything life threatening, most if not all you know with near certainty will outlive the person you're being told to send home.

It's a call I've made many times, to hospitalists, "Just diagnosed Mr. ______ with ____(insert hellish, unexpected and advanced cancer diagnosis)____. Man, what a shame. Although he's stable right at the moment, I can't see sending him home after giving him this news."

Hospitalist, "Well, you know as well as I do, he needs to see heme/onc in the office and admitting him isn't going to speed anything up, right? You know we don't admit these when we find this stuff in the office, right?"

"Well, I know, but geez...."

It's a very difficult thing, that seems emotionally surreal and like it absolutely needs to happen a different way, but often doesn't. Emotionally if feels like if you are newly diagnosed with a serious cancer, that ought to buy you at least the option of admission, considering all the BS that often gets admitted for absurd reasons. But I know a lot of hospitalists and oncologists don't always feel it speeds up the time to treatment. That being said, if someone can truly get treated quicker in the outpatient setting, then by all means get them treated as quick as possible. Having seen so many patients get lost to follow up, over the years, I'm always skeptical when I hear that promise.

We admit bs chest pain, syncope, etc. every single day. My patients have terrible follow-up as it is. I wouldn't feel bad about admitting one of these at 10pm, if only to be d/c 12 hours later in the light of day with a PLAN.

 

[startswithb]

In an academic setting at least it is much better for them to be seen in and plugged into the cancer center, where they can be scheduled with the appropriate subspecialists. Admitting a GU cancer when the GI oncologist is on call and rounds on them in the hospital is not going to be very useful. Similar with surgical consults. Your sexual medicine urologist is not going to make any decisions about a renal mass on an inpatient. I'll ask the ED to complete the appropriate labs/imaging workup before discharge so the specialist has more information in clinic, which usually satisfies everyone. This is for asymptomatic patients.

 

[docdragon]

1. Have a clear reason for admission (dehydration, jaundice, FTT, anemia, pain, dyspnea, PE, etc). Admit.
2. No clear reason to admit except new cancer:
Talk to whichever specialist is most appropriate, whether onc or onc + GI. Community setting, oncology specialty hospital. Few patients have great PMD follow up options, so in general they're going to slip through the cracks.
98% of the time my oncologist says to admit and they'll see them in the morning. IR is happy for a pre-notification for scheduling biopsies if I have time to call. About 2% of the time the oncologist says they'll see the patient in the office within 2-3 days, in which case I've established follow up. If it's the middle of the night then often the hospitalist will just take the patient, knowing that oncology will consult.
I have also worked with really strong outpatient oncology follow up, in which case they'll have an appointment or phone call within 48 hours and they can go home and spend time with family.

Of course, the flip side of a comprehensive oncology center is that when your surgeon on call works out of the cancer center (surg-onc) and patients with biliary colic/stones/etc call for an appointment, they then call the ED totally freaked out to find out why they were referred to the cancer center. Ya learn that one real fast: "Just so you know, Dr. X's office is in the cancer center, so when you call..."

 

[cofcemt]

We admit bs chest pain, syncope, etc. every single day. My patients have terrible follow-up as it is. I wouldn't feel bad about admitting one of these at 10pm, if only to be d/c 12 hours later in the light of day with a PLAN.

This right here. I had a young family member come to visit with neck mass, given his age I was concerned about lymphoma. Had an appt with his PCP 2 days later and he tried the outpatient thing for 6 weeks (with my guidance on how to move through the system) until he started having B symptoms and got admitted and had a diagnosis 4 days later. This is at a major academic center for all visits that's top 5 in the country for lymphoma.

So yeah, after seeing how that went down, of the patient wants admission or has tried to get follow up and hasn't been able to, then I admit these 100% now. The only way I discharge them is if they have an actual appointment time scheduled before they get discharged with the oncologist. I have followed up on a lot of these suspicious cancer diagnosis patients and our oncology group is not great about 2-3 day follow up. The emotional toll on these patients is so great.

Navigating the heathcare system is so difficult for the vast majority of people.

 

[GeneralVeers]

I feel admission is only really possible in a tertiary or academic medical center. My community hospital NEVER has oncology on-call. The only way an admitted patient is seeing an oncologist is if they have insurance, or are already established. Medicaid, or no insurance? Forget about convincing any of the not-on-call specialists to see them. Unless acute life-threatening issue that needs stabilization, I discharge them home. It sucks, but the admission is really a pointless waste of a bed and money.

 

[dchristismi]

Depends on the case, but my practice is very patient dependent. Most of the time, there is an underlying symptom that needs to be managed, and these people get admitted.

I had a case on New Years Day several years ago... one of the few I've ever sent home. Nice guy (of course), whose Obamacare kicked in Jan 1, complaining of "gallbladder problems" for about 6 weeks. Well, his liver was full of mets. We had a long talk, and after some pain meds, his pain was better and he thought it would be better to go home and start sorting out his life. So I sent him home. I do think about him often and was just a sad case altogether. But the vast majority of the time, there is some symptom management required.
I think the patient's mental/emotional state should be weighed in as well - which might very well be the reason for admission (IME, it's dyspnea or chest pain...)

I really hate knowing I'm going to walk into someone's room and destroy their life - from that instant on, everything will change for them. I am pretty good at THE talk, but it doesn't mean I like it.

 

[dchristismi]

Ug. I totally jinxed myself.

Had a very nice lady last night... seen at UC for back pain and dysuria about a week prior, but not getting better on abx. She's a little tender RUQ, oddly, and LFTs are a bit elevated. Been really nauseated despite zofran and now not eating much. So I scanned her.

4.5cm spiculated pancreatic tail mass encompassing the SMA, with dozens of hepatic mets. F.

She wanted to go home to process, but was still nauseated and now freaking out. She didn't have a PCP to grease the wheels (although in all honesty I knew it wasn't going to matter,) which would have been the only way I think we could have managed this as an outpatient, especially given her symptoms.
Still, handing down a death sentence like that just sucks.

Her CA 19-9 level was >100,000. I didn't know it went that high. (No, that's not a test we do in the ER. I was just checking on her, and saw it.)

 

[carbonizedeyesockets]

I recently admitted a patient who had a scan for abd pain and was found to have apparent malignancy in their abdomen. They did not speak english, did not have insurance, and of course did not have a PCP. Got an email that the hospital would not be reimbursed for their 5 day stay. Bummer about reimbursement, but her getting lost to follow-up has a potential to be far more expensive in my city/state. Luckily being in a health system that is academic helped insofar as work-up (they did get seen by multiple specialists, including oncology, GI, and surgery).

The community hospital I work on occasion wants admissions, so there it would little pushback to get the patient a bed, but actually getting seen by onc would be questionable. My thoughts would be more to have the patient get seen by case management and social work to help with insurance and facilitation of out-patient work-up. With a insured, reliable patient, and no other need for admission, I agree that discharge with close out-patient follow-up would be best.