ABSTRACT
Tumour-induced hypercalcemia (TIH) and pain from bone metastases are common complications of advanced malignancy and have a significant negative impact on quality of life. Many cancer patients in the advanced stages of their palliative illness prefer to avoid hospitalization and to receive their care in the community setting. This small open-label prospective pilot study explored the feasibility of administering zoledronic acid intravenously in the community setting (home and residential hospices). It enrolled a convenience sample of 12 patients with advanced cancer and TIH (n = 7), malignant bone pain (n = 3), or TIH and malignant bone pain (n = 2). The mean duration of infusion was 15 minutes (range: 14-30 minutes). The total nursing time required was 95 minutes, and the mean total cost, including nursing time, travel time, and drug costs was $708.97 per infusion. This cost was compared with costs for clodronate and pamidronate ($402.52 and $406.12 respectively). Calcium fell from a mean of 2.97 mmol/L on day 0 to 2.63 mmol/L on day 4 and to 2.54 mmol/L on day 10. Delirium resolved in 2 of 5 patients with TIH-associated delirium. Intravenous zoledronic acid administered in the community to palliative patients at the end of life is feasible and safe, and the short duration of infusion offers advantages to patients and nursing resources alike. The higher cost of zoledronic acid per infusion may be offset by the advantage of its short infusion time.
ABSTRACT
The use of cardiac pacemakers and arrhythmia control devices is increasingly common. The presence of a previously placed pacemaker or implantable cardioverter-defibrillator (ICD) in a terminally ill patient may result in medical and ethical issues for the patient, family, and healthcare provider. Two cases are presented to illustrate the complex issues that may arise in the terminally ill with a pacemaker or an ICD. Based on these cases and a review of published data, it is likely that the disabling of a previously placed pacemaker will neither hasten nor prolong the natural history of the underlying illness in most instances. There are uncommon but potentially severe adverse effects of disabling the pacemaker; therefore, pacemakers should generally be left intact in terminally ill patients. It is more difficult to generalize as to whether deactivation of an ICD is appropriate; in this case death may be hastened and the decision concerning an ICD will depend on the specific clinical scenario. Patient and family education regarding palliative care treatment goals and the function of pacemakers and other implanted arrhythmia control devices can help to alleviate anxiety surrounding the impact of this technology at the end of life.
