High-cost intervention?

Question 1

High cost intervention?

Answer 1

• Diagnosis and treatment of a new problem that does not relate to the terminal illness can be evaluated and treated by the patient’s primary care provider under usual Medicare billing (acute MI in terminal CA)
• No regulation
• Up to the individual hospice agency.
• NOT for psychologically cope with impending death

Question 2

High cost intervention

(nutrition and hydration)

Answer 2

Hydration

• Fluids may be of benefit to treat DELIRIUM in selected patients.
• NOT for psychologically cope with impending death

Enteral

• Selected HIV patients
• good functional status and proximal GI obstruction.
• Hungry patients can NOT take food by mouth: Amyotrophic lateral sclerosis, chemotherapy/XRT involving the proximal GI tract, head/neck CA.
• NO proven survival/aspiration/QOL benifit in advanced dementia, bed-ridden stroke, dying patients from a chronic illness

Question 3

Parenteral nutrition

Answer 3

• NO proven benefit in advanced cancer patients, EXCEPT head/neck
• Good functional patient PSS>50, ECOG 0-2) with non-functional GI: inoperable malignant bowel obstruction, short bowel syndrome, and
  malabsorption.
• Fit with GOC and pt accepts risks and disadventages

Question 4

palliative radiation/ chemotherapy

Answer 4

Treatment is NOT expected to cure but solely for symptom control.

• High effectiveness (Response rate>25%)
• Median Duration of Response VS Patient’s life-expectency (at least >4wks)
• Burden of the treatment.

Question 5

Palliation radiation

Answer 5

Bone metastasis

• 300 cGy x 10 fractions
• Relief begin within the first few treatments and peaks by 4 weeks.
• Surgical fixation prior to XRT is indicated for large lesions, when >50% of the cortex is replaced by tumor, or when fracture has occurred in a weight-bearing bone.
• Strontium89 or Samarium153 or Phosphorous32;
• Peak 3-6 weeks
• BM suppression 10-30%
• ‘pain flare

Epidural metastasis and spinal cord compression

• 300 cGy x 10 fractions + steroid
• preserve functions
• Indications for surgery include no tissue diagnosis, spinal instability, bone fragments causing cord damage and progression during/after XRT

Brain metastasis

• 300 cGy x 10 fractions Whole-brain or stereotactic radiosurgery (‘Gamma Knife’)
• relieve symptoms and prolong survival.

Other indications

• Obstruction: vascular (SVC), esophagus, airway, rectum, biliary tract
• Pain: adrenal metastases causing flank pain, tumors causing nerve impingement
• Bleeding: stomach, esophagus, head/neck cancer, bladder, cervix
• Ulceration/fungation