1. Case Scenario 2 ISCCM/IAPC

2. Mr. Joshi is a 54 year old school principal, diagnosed with pancreatic carcinoma 5 months ago after presenting with a locally advanced, unresectable, pancreatic mass and painless jaundice. He/she underwent surgery to relieve the bilary obstruction and then received radiation and two months of chemotherapy. The chemotherapy was very hard on him/her, causing severe nausea and fatigue. He called the oncologist three days ago saying that over the past 3 weeks he has noticed a decline in energy, generalized fatigue and little appetite. He has no pain or nausea. The oncologist ordered an abdominal CT scan and asked him to come in today.

3. During the CT scan he became severely breathless and a code blue was announced. Your junior resident attended the code & subsequently shifted the patient to ICU. After initial resuscitation, he is started on NIV, put on IV fluids. ECG shows an S1Q3T3 pattern. CXR shows bilateral pulmonary shadows. Differential diagnosis at this point is 1) spread of disease 2) pulmonary embolism 3) pneumonia 4) Reaction to contrast. Pulse is 100/min, BP is 90/70, RR is 36/min and sPO2 is 85% on 60% Fio2.

4. Your judgment is that he requires inotropes, invasive monitoring, IPPV, treatment of the specific cause after investigation. You have spoken to the oncologist who says that patient will not benefit from any further treatment as far as the cancer is concerned. The last chemo was given two weeks back. He has discussed the overall poor prognosis with Mrs. Joshi but has not spoken about limitation of therapy. He requests you to speak to the wife and take further decisions.

5. Questions Explain the current status. Explain the need for interventions Elicit the wife’s opinion. Explain the role of limitation of therapy as maybe appropriate

6. After discussion with the wife, Patient is given a trial of intensive care including all therapy – Arterial line – CVP line – Vasopressors – IPPV About 6 hours later ------------ CTPA shows saddle embolus Urine output is nil BP MAP 50 on maximum inotropes Severe acidosis on ABG Your opinion, and opinion of cardiologist and nephrologist is that further interventions will only prolong the process of dying