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CASE
This 93-year-old woman first came to our hospital via the emergency department (ED). She was transported by local paramedics called by the Department of Senior Services, who made a visit to the patient’s home and found that she could no longer safely remain in her home and care for herself. Following an ED assessment, the patient was admitted to a medical/oncology unit.
She was confused and somewhat combative. She had five children but no power of attorney of any kind. Upon admission, a psychiatric evaluation was ordered and the patient was found to be not competent to make decisions for herself. A daughter was established as power of attorney. During this admission, a small lesion on the patient’s forehead was also noted. Vital signs were normal, and her weight was 130 lb. The history included arthritis, and radiology studies showed a previous right knee fracture. Diagnosis included dehydration, dementia, and failure to thrive. The patient was treated and discharged after 3 days to a nursing home.
One month later, the patient was readmitted to the hospital because the lesion on her forehead had increased in size. In the past 3 weeks, it had grown rapidly into a 3½x2-inch fungating lesion. The tumor invaded the anterior orbital space and infringed on the patient’s vision in her right eye (Figure 1). A biopsy was done, and the pathology report showed stage III squamous cell carcinoma. CT verified that the lesion had not yet invaded the brain. A surgeon was called in for consultation and said that excising the lesion would leave a large deficit and most probably involve enucleation of the right eye. A radiation oncologist was consulted and recommended external beam radiation for 20 treatments.
At the time of this second admission, the patient was disoriented and combative at times. Her weight had decreased to 106 lb. The primary care physician and radiation oncologist informed the patient’s family that external beam radiation therapy would require the patient to be under anesthesia for each treatment and that foregoing treatment would mean that the lesion would invade the brain and continue to grow onto a larger portion of the face.1 The family decided that the patient should be discharged back to the nursing home to return to the radiation therapy department daily to receive external beam therapy under anesthesia.
Treatments were provided to the patient over the next month. Because IV access was poor, a peripherally in- serted central catheter (PICC) was required midway through the treat-ments. The daily treatments were administered in the early afternoon because the anesthesiologists were involved in surgical procedures in the morning. The patient was NPO from 6 am until the treatment was completed and was taken to the recovery room afterward. During the month of radiation therapy, her weight declined further and a gastric tube was inserted.
The patient returned for follow-up 3 months after treatment had ended with the lesion healed (Figure 2). Although she was still slightly confused, she was noncombative and pleasant. Her weight had increased by 8 lb, and the vision in her right eye had returned.
