1. Case Discussions Challenges in End of Life Care 15/11/14 MR D

2. MR D 73 year old Man  Lung cancer 2 years ago- (treated)  4 mnth ago radiotherapy for humerus mets - Gradual decline over few months. Tired but independent  Lives with wife who has MS but is mobile  Hates hospital. Preferred Place of care- own Home  PMH: MI 6 yrs ago and BPH  Meds: Oxycontinin, Oxynorm, Pregabalin Tamsulosin PPI, Aspirin, Statin, ACE

3. Phone call Wednesday 2.30pm  Vomiting and generalised pains  Bowels open 2-3 days ago  Has not pu’d since early hours  Not well enough to come to surgery

4. GP Visit  In Bed- Not well  Temp 38.2, Pulse 105,  Vomiting  Abd soft- Some loading of bowel  Bladder just palpable - slightly tender  Patient and wife distressed

5. WHAT ARE YOUR THOUGHTS?

6. Discussion  Differential Diagnosis  Patients doesn’t want to go into hospital  What more history and examination?

7. What happened next  Patient didn’t want to go into hospital  DN catheterised patient: some blood ?infection  Antiemetics given subcut  Patient settled but has some new back pain  Examined CNS  Decrease power and tone L leg  Some sensory impairment  Patient then agreed to admission for MRI  Steroids started at home

8. Metastatic spinal cord Compression  Admit to nearest hospital with facility for MRI  Inform ambulance: stretcher required. Admit within 1 hr  Ensure letter/phone call state possible MSCC  If available give 16mg dexamethasone orally