1. Case Discussions Challenges in End of Life Care 15/11/14 MRS B

2. Visit request Mon Afternoon (temp resident)  From daughter: Brought Mum to stay with me  Has Renal cancer  Tired/Sleepy  Not Eating/drinking  Just not herself

3. MRS B History from daughter  Age 77, Temp Resident  RENAL CANCER, LUNG METS Diagnosed 8/12. Palliative Rx, 12/12 prognosis  PMH  Hypothyroid  Medication  Levothyroxine, Oxycontin/Oxynorm  Allerg: Dexamthazone

4. History and exam Mrs B

5. Discussion with Mrs B and daughter  Daughter struggling  Mrs B will consider admission to Hospice but nowhere else  BUT NO FEMALE BEDS IN HOSPICE

6. WHAT DO YOU DO NOW?

7. Discussion  Differential diagnosis  Patient’s wishes  Carer’s wishes

8. WHAT HAPPENED NEXT?  Urgent bloods requested (done next day)  Referred to ERT  Next day  Increased confusion and reduced mobility  Still no Hospice bed available  WHAT NEXT ?

9. Patient Admitted to hospital  Calcium 3.34 (2.20-2.60)  Albumin 32 (35-60)  ALP 245 (30-130)  Bilirubin 9 (<21)  ALT 7 (< 35)  GGT 62 (<35)  CRP 38 (<5)  Urea 9.3 (2.5-7.8)  Creat 90 (50-130)  Egfr 47 (>60)  Hb 94 (118-148)  WBC 25.6 (3.5-11)  NEUTS 22 (2.0-7.5) Then bloods phoned through

10. Other tests in Hospital  CT Head – normal  CT Chest/Abdomen/Pelvis – Increase in renal mass and pulmonary metastases  MRI Spinal Cord-  No spinal cord compression  Evidence of rib invasion from metastases  Urine/ Blood Cultures – negative

11. TREATMENT:  IV Fluids  IV Bisphosphontes  Confusion settled  Mobility improved  Discharged to own home.