Case Scenario

Dr. Ganesh Kumar, MBBS, DA, MRCA and Sreekumar Kunnumpurath, MBBS, MD, FCARCSI, FRCA, FFPMRCA

Mariano is an 82-year-old millionaire industrialist who was diagnosed 2 months ago with advanced carcinoma of the pancreas. Though he has extensive bony metastasis, his main problem is severe, intolerable abdominal pain. His physician has requested that you, an interventional pain specialist, assess Mariano for a possible neurolytic celiac plexus block. He is doing so in order to keep the pain under control to enable the patient to be discharged and sent home. Mariano has expressed his desire to spend the last days of his life with his family.

Before meeting with Mariano, you decide to go through his medical records that show that his liver function tests are abnormal and his clotting is slightly deranged. His other medical problems include a 4 cm size aortic aneurysm, COPD, and hypertension. The MRI scan shows extensive degenerative changes of the spine and metastatic lesions on the lower thoracic vertebrae. A prior exploratory laparoscopy found the pancreatic tumor to be inoperable, and hence he had a course of palliative chemotherapy. You walk into Mariano's room and you notice that he is on PCA morphine and appears to be asleep with his son, Rocco, at his bedside. Rocco tells you that he does not want his father to be disturbed from his sleep and he asks you to discuss the procedure with him instead. Rocco says he is concerned that the morphine is making his father a "drug addict" and so he wants the celiac plexus block to be done so that the morphine can be stopped and his dad can make clear decisions about his estate and finances before he dies. Rocco requests you to proceed straight away and he says that presently his father cannot make any decisions for himself because of the morphine.

Do you agree with Rocco?

No necessarily. You always have to respect patient's autonomy. The other guiding principles in this situation include nonmaleficence, beneficence, and justice. So you have to reason with Rocco and tell him that first, you have to assess his dad in detail, including his mental capacity. "Capacity" is determined by the attending physician at the time of the interview with the patient that the patient is able to understand the therapeutic options and their inherent risks and benefits, can ask questions and process the answers, and make an informed decision about what he/she would like done or not done. This ability to have "capacity" to make health care decisions is not necessarily impaired by medications such as opioids; and does not require that the patient remember the conversation even 1 hour later. "Competency" on the other hand is the ability of the patient to make financial decisions about his/her will, and other socioeconomic decisions. This can be challenged by family members and is usually decided by a psychiatrist or a judge. If you are still in doubt about his ability to give a valid informed consent, then he will have to be assessed by a psychologist. You will also have to address Rocco's "Opiophobia." At this moment, Mariano wakes up and says, in a sleepy voice, "Hello doctor! Is my son is troubling you too? Do not listen to him. I am still the boss! You may ask me whatever you want to know."

What would you like to ask Mariano?

You need to assess whether Mariano is cognitively intact or not. If he is, then you can collect some detailed history, perform clinical examination, and complete your assessment. Mariano appears to be acting as if he is pretty much at his cognitive baseline. You discuss all of the pain management options with him in detail. Mariano asks you about the planned celiac plexus block and you explain potential risks and benefits. After the discussion, Mariano decides that he does not want to have the celiac plexus block as he wishes not to undergo any invasive procedures and he does not accept the risk of complications related to this block. He prefers to "die with dignity" at his home. He is very happy about the pain relief that he is receiving and would like to continue with current regimen. Impressed with your conduct, he requests you to take care of his pain from now on.

Would you accept his request?

There is no reason why you should not. However, in the given situation it is advisable to have an "opioid contract" signed between you and Mariano to avoid future litigations. Accepting his request would mean that you are not just an interventional pain management physician but that you would now be taking over the role of palliative care physician and you must have the resources to manage his care at home. It would be more appropriate to suggest home hospice care and that you would be able to participate in the management of the care provided by the hospice team. You should also explain that it would be better to try and convert him to oral long acting opioids such as methadone or sustained release morphine so that he would not have to have the intravenous medications and the intravenous access that the PCA requires. If he insists on having the PCA and since he has the financial resources, he can afford to pay for the extra costs, and he should have a more permanent intravenous access such as a chemo port inserted. Your decision to avoid the celiac plexus block might be challenged in a court of law and hence a consultation with the hospital legal department may be necessary.

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