A pilot study of palliative medicine fellows' hospice home visits.

This was a prospective descriptive study of hospice physician home visits (HVs) conducted by Hospice and Palliative Medicine Fellows. Our objectives were 1) to improve our knowledge of hospice care at home by describing physician HVs 2) to identify the indications for physician HVs and the problems addressed during the HV. Data was collected on 58 consecutive patients using a standardized form completed before and after the home visit. More than half of the persons were women. Most were Caucasian. Median age was 75 years; 57% had cancer; 77% were do-not-resuscitate. 76% HV occurred in the home. The median visit duration was 60 minutes; median travel distance and time 25 miles and 42 minutes, respectively. A hospice nurse case manager was present in 95%. The most common issues addressed during HVs were: health education, symptom management, and psychosocial support. Medication review was prominent. Physicians identified previously unreported issues. Symptom control was usually pain, although 27 symptoms were identified. Medications were important; all home visits included drug review and two thirds drug change. Physicians had unique responsibilities and identified important issues in the HV. Physicians provided both education and symptom management. Physician HVs are an important intervention. HVs were important in continuity of care, however, time-consuming, and incurred considerable travel, and professional time and costs.

Symptom management: an important part of cancer care.

Physicians can do a better job of palliating symptoms and improving the quality of life of cancer patients if they understand the principles of symptom management. We review the general principles of symptom management for fatigue, anorexia, constipation, dyspnea, nausea, and vomiting.

Nausea and vomiting in advanced cancer.

Nausea and vomiting are relatively common in advanced cancer and is dreaded more than pain by patients. The history, pattern of nausea and vomiting, associated symptoms, and physical examination provides clues as to etiology and may guide therapy. Continuous severe nausea unrelieved by vomiting is usually caused by medications or metabolic abnormalities, while nausea relieved by vomiting or induced by eating is usually due to gastroparesis, gastric outlet obstruction, or small bowel obstruction. Drug choices are empiric or based on etiology. Metoclopramide has the greatest evidence for efficacy followed by phenothiazines and tropisetron. Corticosteroids have not been effective in randomized trials except in the case of bowel obstruction. Treatment of nausea unresponsive to first-line medications involves rotation to medications which bind to multiple receptors (broad-spectrum antiemetics), the addition of another antiemetic to a narrow-spectrum antiemetic (a serotonin receptor antagonist such as tropisetron to a phenothiazine), rotation to a different class of antiemetic (tropisetron for a phenothiazine), or in-class drug rotation. Venting gastrostomy, octreotide, and corticosteroids will reduce nausea and vomiting associated with malignant bowel obstruction.

5-fluorouracil-induced coronary vasospasm.

BACKGROUND: Cardiotoxicity is a rare but well-documented adverse effect of 5-fluorouracil (5-FU). The underlying cause of this side effect of 5-FU is uncertain. METHODS: We present a case report of a 63-year-old man treated for metastatic colon cancer who experienced chest pain while being treated with the FOLFIRI regimen. This case report documents coronary artery spasm on catheterization observed with the continuous infusion of 5-FU. RESULTS: Cardiac catheterization obtained within 36 hours of the onset of chest pain revealed marked coronary vasospasm in the obtuse marginal coronary artery and a right coronary artery with a critical obstructive atherosclerotic plaque. Electrocardiogram revealed the myocardium area associated with the event was diffuse rather than localized to the right coronary artery. CONCLUSIONS: This observation supports the vasospastic hypothesis for 5-FU-induced angina. Although rare, this type of cardiotoxicity with 5-FU is a potentially lethal side effect. Therapy with 5-FU should be discontinued and patients should be promptly treated.