End-of-Life Care Discussions in Patients With Advanced Cancer

A 70-year-old man with a history of a Gleason 9 (4 + 5) adenocarcinoma 10 years before that was treated with a radical prostatectomy presented to his primary care physician with a complaint of rectal pain that had persisted for several weeks. A large palpable mass was found on a digital rectal exam and was noted on sigmoidoscopy to cause extrinsic compression of the rectum. A biopsy of the perirectal mass was consistent with metastatic carcinoma that was consistent with a recurrent metastasis of his previous prostate adenocarcinoma, now with small-cell transformation. A computed tomography scan showed the perirectal mass arising from the prior prostatectomy bed, as well as a large hepatic mass and bilateral lung nodules that were consistent with metastatic disease (Fig 1). He had lost 20 lbs over 3 to 4 weeks and complained of progressive fatigue, poor appetite, severe tenesmus, and rectal pain. He presented to the medical oncology department for an initial consultation. Given his significant rectal pain and declining functional status, he was referred for palliative pelvic radiation to be given with concurrent single-agent chemotherapy. The patient had been living independently on the West Coast but had relocated to the East Coast to be closer to his adult children. He stressed that his wishes were to remain as independent and functional as possible. He named his eldest son as his health care proxy but did not have an advance directive or living will. After the visit, the patient's daughter approached the oncologist with concerns about discussing "CPR" (cardiopulmonary resuscitation) and "life support," and indicated that this discussion would be overwhelming for her father.