Delirium in a Palliative Care Unit

Abstract

Intractable pain and other intolerable symptoms or the patients' wish to exercise self-determination can mandate palliative sedation. Yet, three bioethical principles must be balanced in comparable situations: one and two being beneficence (to do the best for our patient) and non-maleficence (do no harm) versus patient autonomy (the right for self-determination). Theoretically, palliative sedation incurs the potential risk of accelerating death, particularly in cases in which the disease is not advanced, because the consequences of sedation (perhaps no calorie or fluid uptake) would be likely to cause death (refusal to eat or drink sufficiently). If, however, the disease is far advanced (and the prognosticated life-span short) and the patient unwilling to eat and drink anyway, then initiated sedation might not be associated with accelerated death (and thus do harm to the patient, from an external viewpoint). Therefore, palliative sedation continues to be an area of discussion and a challenge as to when and how to implement it. Here, we introduce the case of a patient with advanced gastric cancer who asked for palliative sedation. We briefly describe his and the family's thoughts and follow the course of the disease until his death. With this report, we re-emphasize that, with precise sedation by continuous infusion of midazolam, it is possible to let the patient wake up for voiding and defecation and communicate with family members. By such individual approaches, it is possible to let the natural course of disease continue. Our patient had at no point in time asked for physician-assisted suicide.     

Is Chronic Pain a Disease?

It was not until the twentieth century that pain was considered a disease. Before that it was managed medically as a symptom. The motivations for declaring chronic pain a disease, whether of the body or of the brain, include increasing its legitimacy as clinical problem and research focus worthy of attention from healthcare and research organizations alike. But 1 problem with disease concepts is that having a disease favors medical solutions and tends to reduce patient participation. We argue that chronic pain, particularly chronic primary pain (recently designated a first tier pain diagnosis in International Diagnostic Codes 11), is a learned state that is not intransigent even if it has biological correlates. Chronic pain is sometimes a symptom, and may sometimes be its own disease. But here we question the value of a disease focus for much of chronic pain for which patient involvement is essential, and which may need a much broader societal approach than is suggested by the disease designation.PerspectiveThis article examines whether designating chronic pain a disease of the body or brain is helpful or harmful to patients. Can the disease designation help advance treatment, and is it needed to achieve future therapeutic breakthrough? Or does it make patients over-reliant on medical intervention and reduce their engagement in the process of recovery?     

Systemic lupus erythematosus. A diagnostic and therapeutic puzzle

Systemic lupus erythematosus (SLE) constitutes a model autoimmune disease characterized by a heterogeneous patient population, diverse manifestations, and disease flares and remissions. Consequently, individualized treatment programs are essential. Given the significant toxic effects of corticosteroid and immunosuppressive therapy, minor disease activity in SLE should be managed conservatively. In contrast, major disease activity is potentially life-threatening; thus, it should be treated as aggressively as possible to rapidly restore organ function. By using the clinical and laboratory parameters now available, the clinician can diagnose SLE early in its course and monitor disease activity and patient response to treatment.     

肠白塞引发消化道出血 1 例

白塞病是一种影响多系统的慢性复发性疾病,当累及胃肠道时,称之为肠白塞,可有胃肠道溃疡、出血、穿孔等表现,但因缺乏特异性而极易误诊阑尾炎、炎性肠病等。本文报道 1 例肠白塞患者的诊疗经过,并结合文献复习,讨论其诊疗进展。      

Peripheral labyrinthine causes of dizziness

A patient's complaint of dizziness must be defined specifically. Many dizzy patients do not have labyrinthine or balance system disease. The patient with dysequilibrium, on the other hand, often has a balance system disease but not necessarily a labyrinthine disorder. The patient with vertigo most likely has labyrinthine disease. Vertigo is accompanied by nystagmus, which can be identified only when the examiner specifically looks for it. Although vertigo is the classic symptom of labyrinthine disease, not all labyrinthine diseases have associated vertigo. Careful history taking, physical examination, audiometry, caloric testing, electronystagmography, and radiographic studies will identify patients with labyrinthine disorders. Treatment depends on the diagnosis. Usually it is medical, but occasionally it may be surgical. Most patients have no residual problems; a few have permanent disability.     

Psychological and psychosomatic problems of oncology

The paper concerns the issues of medical ethics and deontology in communication of a physician with cancer patients and their relatives. Ethic and deontological norms dictate the necessity to approach each patient individually, especially in terms of giving information about the disease. While informing the patient truly about his/her disease, it is important to keep the patient hoping and focus his/her efforts on radical treatment if the disease is not too advanced. If it is so, the patients need individual and group psychotherapy which is able to improve quality of life and to prolong the survival in cancer patients.     

Ceruloplasmin in Wilson''s disease

Ceruloplasmin was highly purified from one patient with Wilson's disease and partially purified from a second unrelated patient. The highly purified ceruloplasmin was indistinguishable from normal ceruloplasmin by electrophoresis, tryptic peptide map, oxidase activity, and copper, amino acid, and sugar composition. The partially purified ceruloplasmin was indistinguishable electrophoretically from normal ceruloplasmin. With penicillamine therapy, ceruloplasmin disappeared from the serum of the first patient; it reappeared after the drug was discontinued. The significance of this observation in regard to the basic defect in Wilson's disease is discussed.     

‘Meaningful Communication': can it enhance the Quality of Life?

In treating malignant disease it often seems that the medical profession is primarily concerned with affecting cure or prolonging life, athough it is clear that both the disease, and its treatment, may profoundly affect the patient's normal lifestyle and have a significant effect on the quality of life (QL). Yet the current emphasis on total patient care means that it is no longer enough to be concerned only with the physical aspects of care; the psychosocial effects of disease are becoming increasingly important. Consideration of the patient's QL is a legitimate part of care and interventions can be designed to help the patient to incorporate changes in his physical state into his normal lifestyle. This paper discusses the concept of quality of life and explores the benefits of 'meaningful communication' (education and supportive counselling) in terms of the relief of stress and anxiety. It considers the effects of such communication on the quality of life of affected patients. It is suggested that the latter can be significantly improved through communication.     

Spinal cord compression due to an aspergilloma

Aspergilloma is a common complication of cystic lung disease; it is widely considered to be a saprophytic colonization and local or disseminated invasion is unusual. We describe a patient with stage IV sarcoidosis and bilateral aspergillomas in whom locally invasive disease led to spinal cord compression.     

Kohler's disease presenting as acute foot injury

Kohler's disease is rare cause of foot pain and limping in the pediatric population. The exact etiology of Kohler's disease is unknown. It usually presents as sudden and unexplained foot pain and limping. We report a case of a 5-year-old male who presented to the Pediatric Emergency Department with foot pain and inability to bear weight for two days after overactivity and acute foot injury. The patient was eventually diagnosed with Kohler's disease (avascular necrosis of the navicular bone). Although Kohler's disease is not very common, it should be considered in the differential diagnosis of foot pain in the pediatric population, as it may prevent unnecessary tests and treatments.     

Using Preoperative Assessment and Patient Instruction to Improve Patient Safety

Rates of patient transfers, cancellations, and patient visits to the emergency department after discharge are quality metrics for ambulatory surgery centers. To improve these metrics, it is imperative to establish best practices for conducting preoperative assessments, including identifying key patient conditions (ie, obstructive sleep apnea, cardiovascular disease, reactive airway disease, obesity). To guide appropriate patient selection, practitioners should review the patient's allergies and sensitivities, alcohol use, medications, and medical history. To help ensure good patient outcomes, it is imperative to provide complete preoperative instructions (eg, NPO guidelines, medications, what to bring, cancellation instructions) and discharge instructions (eg, postoperative medications, appropriate activity restrictions, diet, surgical and anesthetic side effects, special circumstances [eg, regional blocks], symptoms of possible complications, treatment and tests, access to postdischarge follow-up care). Generally, the routine outpatient surgical patient is discharged home; however, there are circumstances that occasionally necessitate transfer or admission to a higher level of care. For transfers, ambulatory surgery centers should adhere to applicable federal and state guidelines and should have a clear policy in place to guide transfers.     

KOCH'S OR CROHN'S?

Abdominal tuberculosis is not uncommon in the UK, especially in Asian immigrants. It resembles Crohn's disease clinically and radiologically, and it may be difficult to differentiate between them, even at laparotomy or histology. The distinction is important, however, for proper management of the two conditions. Every effort must be made to exclude abdominal tuberculosis before the patient is diagnosed as having Crohn's disease and is treated with steroids.     

Diagnosis and treatment of Paget's disease of bone

Paget's disease of bone (also known as osteitis deformans) is a nonmalignant disease involving accelerated bone resorption followed by deposition of dense, chaotic, and ineffectively mineralized bone matrix. The origin of the disease is unknown, and it is frequently asymptomatic; however, the patient may present with symptoms depending on the bones involved. The most common symptom is pain in the affected bone; neurologic, hearing, vision, cardiac, and oncologic complications are possible. Diagnosis is primarily made by radiographs. Bisphosphonates are the most common treatment.     

A patient with adult Still's disease with an increased Chlamydia pneumoniae antibody titer

 Adult Still's disease is an important differential diagnosis of pyretic disease and it does not necessarily appear to be a distinct disease entity. The etiology of adult Still's disease is not yet known. However, it has been considered that adult Still's disease may be triggered by certain infections, such as the Coxsackie, parvo B19, rubella, mumps, Epstein-Barr, and cytomegalo virus, as well as mycoplasma, toxoplasma, and so on. Recently, we experienced a patient with adult Still's disease with an increased Chlamydia pneumoniae antibody titer. The titer decreased slowly after the beginning of steroid therapy, associated with improvement of clinical symptoms. In this report we mention the relationship between the pathogenesis of adult Still's disease and a high titer of Chlamydia pneumoniae antibody. Received: November 2, 2001 / Accepted: April 8, 2002     

Colonic perforation following mild trauma in a patient with Crohn's disease

A 26-year-old man with a history of Crohn's disease was struck in the abdomen by an opponent's shoulder while playing basketball. He presented to the emergency department 3 hours later with the complaint of abdominal pain and was admitted to the hospital for observation. Nine hours after presentation a computed tomography scan showed he had pneumoperitoneum and then underwent laparotomy. A perforated segment of sigmoid colon with severe inflammatory disease was found and resected. The rest of his small and large bowels were otherwise unremarkable. His localized but severe inflammatory bowel disease predisposed him to bowel perforation with minimal trauma. This is the first report of a patient with inflammatory bowel disease and traumatic colon perforation; it is also the first report of a patient with a bowel perforation with minimal traumatic force.     

A young onset Parkinson's patient: a case study.

Young onset Parkinson's disease (YOPD) is defined as idiopathic Parkinson's disease (IPPD) occurring in people between 21 and 40 years of age; it strikes approximately 5% of Parkinson's patients. YOPD has earlier onset of motor complications than later onset Parkinson's disease. Motor complications and disease progression are responsible for devastating morbidity. Current medical and surgical treatments can dramatically ameliorate motor complications and help maintain function and employment. Patient education, support, and advocacy provided by nursing staff can influence the treatment options for these patients, having a significant effect on the future course of the disease. This case history documents the course of a YOPD patient with unusually severe motor complications. He is the only patient at Puget Sound Neurology ever to develop rhabdomyolysis due to dyskinesias. Following bilateral subthalamic nucleus deep brain stimulation, his Parkinson's symptoms have improved dramatically, and his motor complications are significantly improved.     

Case Report: Emergency Department Diagnosis of Melorheostosis in the Upper Extremity: A Rare Disease with an Unusual Presentation

Background

Melorheostosis is a rare disease that affects fewer than 1:1,000,000 persons worldwide and most typically affects the lower extremities. It is a non-hereditary disease that may be debilitating due to chronic pain, contractures of the soft tissue, and even shortening of the affected limbs. Although it most commonly occurs in the lower extremities, melorheostosis has been reported in various locations throughout the body.

Objective

This case report describes a patient who presented to the Emergency Department (ED) with this rare disease in an uncommonly affected bone.

Case Report

The patient was a 21-year-old man who presented to the ED with pain in his left upper extremity that he attributed to playing sports 3 days before presentation. Plain films revealed periosteal hyperostosis typical of melorheostosis in several of his carpals, metacarpals, and phalanges, as well as the humerus and ulna. The patient was discharged with orthopedic follow-up and pain medication.

Conclusion

Melorheostosis is a rare disease that has characteristic radiographic findings likened to the appearance of melting wax flowing down the side of a candle. In certain cases, the disease can be debilitating and may require chronic pain management and even operative intervention. If this diagnosis is made in the ED, the emergency physician should provide adequate pain management and refer the patient to an orthopedic specialist for a work-up to rule out other sclerosing bone dysplasias.     

Bilateral, spontaneous, concurrent patellar tendon rupture

Bilateral rupture of the infrapatellar tendon is extremely rare. When it occurs, it is almost always associated with connective tissue disease. We present a case of bilateral concurrent rupture of the patella tendon in a patient without any apparent systemic disease.     

A rare case of a prostatic abscess,bacteremia and chronic granulomatous disease associated with Klebsiella pneumoniae

Chronic granulomatous disease (CGD) is a primary immunodeficiency disease characterized by severe recurrent infections such as pneumonia, liver and skin infections. However, prostatic abscesses are rare as only two cases have been reported thus far. We present the case of a 41-year-old patient with CGD who was admitted to the hospital with fever and subsequently, Klebsiella pneumoniae was identified on blood culture. Abdominal computed tomography revealed a prostatic abscess. He improved with intravenous antibiotics and drainage of the abscess. After he was taken off the intravenous antibiotics and started on an oral agent, he was discharged from the hospital. We confirmed a reduction in the prostatic abscess size and continued the antibiotic therapy for 52 days. A prostatic abscess is an uncommon disease being diagnosed at a median age of 49 years. Sometimes it is discovered in patients with fever of unknown origin and might be considered as an infection site of CGD patients.     

Gedanken zur Betreuung terminal Kranker mit Krebsschmerz

When treating a cancer patient with severe pain it is not sufficient to treat the cancer and the pain. Effective therapy must adhere to the principles of psychosomatic medicine, i.e., the disease, cancer, isnot treated, but instead a human being who is suffering from this disease, has severe, ongoing pain as a result, and is going to die. Irrespective of the question of whether the patient has been told his diagnosis or not, he will be in an extreme situation psychologically, as he instinctively suspects what is wrong with him. Pain indicates that the cancer is advanced; this can be compared with a death sentence, the execution of which has not yet been definitely scheduled. In these cases continuing care is more important than formal therapies. Above all, a cancer patient fears "intractable" pain, the prospect of being helpless because of physical deterioration, and imminent death which is no longer hypothetical. In order to assure adequate pain therapy, the pain medication must be continuous and sufficient, administered on a regular basis and given irrespective of whether there might be side effects or not. This requires that there be a relationship of confidence between the physician and patient in order to ensure compliance of treatment. As morphine is the most powerful analgesic drug, it can and must be given at an early stage. The fear of impending helplessness can be reduced by the physician "accompanying" the patient providing loving care, and assuring the patient that he will have somebody to rely on when he needs it. The most important way to solve such problems is to have a dialogue addressing the problems. Verbalization of fears can resolve them; even fear of death can be reduced when it is addressed in a dialogue. Advanced cancer patients are mostly remote from everyday life; they no longer take part in it. If, however, they receive the proper guidance, they will live more consciously and more intensively. In the awareness of imminent death they can experience every day of their life as a gift. Care of terminally ill cancer patients with severe pain thus also must include a guided approach to death.