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PMR 4 MSK

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It's not often I have to be the one to tell someone they have cancer.

Today - 87 yo male, prostatectomy 18 years ago for prostate cancer, had radiation, no chemo. Presented last week referred by ortho for increasing back and neck pain, at it's worst while he sits for 4 hours during dialysis. Radiating into the arms and legs, variably, vaguely, +/- numbness/tingling. Difficulty walking x several months, so I'm thinking stenosis +/- facets +/- listhesis. He's had xrays, PT and meds, including Duragesic 50 + Hydrocodone recently. Even with that he's having difficulty making it through dialysis (not sure why his kidney's failed).

I get a call from the radiologist about his lumbar MRI from Friday while he is back today for the cervical MRI (Medicare doesn't pay for 2 in the same day). L-Spine is loaded with mets, blastic looking. I look at the C-Spine MRI, it is too. I have our MRI tech stop them before they leave.

Pt is quite sedated from the Ativan they gave him this am at the nursing home he's in to help him get through this MRI, so he's out of it, plus too HOH to know who or what we're talking about. His daughter is with him. I tell her what I know. She tells me his PSA has been rising lately, not sure of the level. She also tells me in the past couple years she's lost her husband and mother to cancer. I call the PCP to tell him, he's not suprised and says he'll take it from there. Both the PCP and the daughter indicate that the patient will likely refuse palliative radiation, and will likely withdraw from dialysis and let himself die. Hopefully they'll go with hospice. Daughter quite distraught but trying to hold herself together when they left.

So my only role for this family has been the diagnostician and bearer of bad news. At least he'll get to choose relatively when and how he'll die.

What a way to start off your week... :(
 

Ludicolo

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I've lurked around here long enough...

Speaking as someone invested in the field of cancer rehab - I know where you're coming from. Part of my job is sometimes diagnosing recurrent or metastatic disease in someone felt to be in remission. Sometimes these patients are candidates for further treatment (surgery, chemo, radiation) - sometimes not. The ones that proceed with treatment, frequently they do have alleviation of pain and return of function. We can certainly enhance their pain relief and functional restoration through all the things rehab docs do - medications, injections, PT/OT, orthoses, etc. For these patients, obviously we have done them a service. For the patients where further treatment isn't a reasonable option, moving them toward hospice may certainly make them comfortable and ease the burden of care off family members, enhancing quality of end-of-life - part of the continuum of care and not a trivial thing.

Sometimes we practice physical medicine, sometimes we practice rehabilitation medicine. Always we practice medicine. I think you did good.
 

PMR 4 MSK

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Talk about going fast. Same patient was admitted to the hospital this weekend, obituary in the newspaper today.
 
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