Total Pain Management and a Malignant Wound: The Importance of Early Palliative Care Referral

Abstract

Breast cancer may metastasize to the lung, liver, bone, brain, and skin, with especially high rates of metastasis to skin sites.These skin metastases are called malignant wounds. Patients with malignant wounds often report multiple symptoms, and pain is one of the most common and distressing among them. Despite the availability of multiple guidelines about treatment to relieve pain, almost half of all cancer patients still receive inappropriate care for pain. A multidisciplinary approach can improve outcomes in terms of symptom control and quality of life and enable the detection of previously unmet needs of both patients and caregivers. Palliative care is a multidisciplinary therapy that aims to alleviate physical, psychological, and emotional suffering in patients at any stage of the disease. We present the case of a 53-year-old male with a three-year history of stage IV breast cancer. He was admitted to the internal medicine ward in July 2021 with uncontrolled pain related to a malignant wound in the left hemithorax. This was a case with physical, emotional, social, and existential factors contributing to severe pain, necessitating a multidisciplinary approach for adequate relief. Opioid titration and insomnia and anxiety treatment were initiated. Dressing care was applied with metronidazole impregnation and aminocaproic acid for hemorrhagic spots, followed by fat gauze. He was proposed to undergo antalgic radiotherapy, which was unfortunately associated with new onset of symptoms. Psychological support was provided for the patient and his family. We managed to control the pain and stabilize the wound; however, cachexia become evident with the disease progression. In the last week of his life, the patient still believed he would be able to undergo chemotherapy. He died in the emergency room, where he had gone to seek relief for uncontrolled symptoms. Even though the patient had an incurable disease associated with immense suffering since early 2019, he was only referred to the palliative care team during the last three months of his life. Existential suffering was an important dimension of this patient’s pain and was present until his death despite receiving psychological support. Late referral to palliative care is unfortunately frequent and often associated with poor quality of life and inability to plan or make end-of-life care decisions. Radiotherapy was proposed for pain control but was associated with serious side effects. In a palliative care setting, decision-making always needs careful consideration related to benefit versus harm and must involve the patient and his family. Living with stage IV cancer is an everyday challenge for patients, and clinicians may also find managing such patients very arduous and stressful. Symptoms must be actively studied and evaluated from a multidimensional perspective. Managing expectations throughout this process while maintaining hope is a delicate balancing act and should be undertaken by specialized palliative care teams.

Translation and Validation of the Greek Version of the Questionnaire for Assessing Fear of Radiotherapy in Oncology Patients

“…Some participants reported experiencing less anxiety when family and/or friends helped them with hospital appointments [ 5 ]. On the other hand, according to a supporting study, cancer patients harbored fears of relying on caregivers [ 19 ]. The fear of dependency was one of the reasons leading to suicidal thoughts and exacerbating the patient’s psychological well-being.…”

Positive Psychological Well-Being in Early Palliative Care: A Narrative Review of the Roles of Hope, Gratitude, and Death Acceptance

“…Koch and Mantzouris [60] and Faria and colleagues [61] described clinical cases where a failure to initiate EPC resulted in patients seeking aggressive treatments and eventually dying without being informed of their true life expectancy. In these cases, the contrasting meanings that hope may assume for stakeholders in a terminal illness context (healing vs. achieving optimal quality of life) are explored, and depending on the attributed meaning, the outcome of the situation can be either unfavorable or desirable.…”

“…While detailing the case, the authors recognized that conveying the prognosis and the approach to end of life does not take away hope; instead, it reframes it as an attainable quality of life. Faria and colleagues [61] detailed the case of a 53-year-old male diagnosed with stage IV breast cancer who experienced unmanaged pain resulting from physical, emotional, social, and existential distress. The authors underscore how, despite being aware of having an incurable disease, the patient retained optimistic expectations concerning potential treatment options.…”