CASE REPORT :Palliative Care in a patient with Renal Cell Carcinoma

Author : Dr. Ashwathi G,
DNB Resident, Dept. of Family medicine,
Lourdes hospital, Kochi
Co-authors: Dr. Varghese Jomy, Senior Resident
Dr. Resmi S Kaimal, Head of the department.
Dept. of Family medicine, Lourdes hospital, Kochi

Introduction

Palliative care improves the quality of life of patients and that of their families who are facing challenges associated with life-threatening illness, whether physical, psychological, social or spiritual. The quality of life of caregivers improves as well. Each year, an estimated 40 million people are in need of palliative care; 78% of them people live in low- and middle-income countries. Worldwide, only about 14% of people who need palliative care currently receive it.

Below we have highlighted a case report of a patient we managed. We describe the problems that were identified and how we addressed each of them.

Case report

54 year old male attended family medicine OPD with complaints of generalized tiredness and abdominal distension. He was diagnosed with Renal Cell Carcinoma with inferior venacava and liver metastasis 3 months back. On examination, vitals were stable, and on abdominal examination patient had ascites.

Problems recognized and how we worked with them.

1. False assurance Patient was diagnosed to have malignancy 3 months back. He could not afford surgery in private hospitals and was deferred surgery in medical colleges due to COVID 19 situation. He opted for treatment in alternative system of medicine and was assured complete cure in 1.5 years.

What we did?

Care takers were initially counseled about nature and prognosis of the disease. They were educated regarding mental and financial burden alternative medicine can cause.

2. Dealing with collusion.

Most patients diagnosed with a life-threatening illness want to know the truth regarding their situation to enable them to plan their remaining time their family's future The family members were aware about the situation while patient was not aware of the same.

What we did?

Both the caregivers and patient were educated separately. Diagnosis and prognosis of the disease were explained in detail. Patient was given time and arrangements were made to fulfill his wishes.

3. Urinary obstruction

Patient had complaints of hematuria. Alternative system practitioners convinced him that it was the tumour itself, which was being excreted in urine, which was good for the disease treatment. Patient was hence considering it as a good prognostic sign. Blood clots caused acute urinary obstruction.

What we did?

Patient was catheterised. Blood clots caused blockage in Foley’s catheter as well. Continuous bladder drainage was done with 24 Fr Foleys using 3 L saline and clots were removed. Patient was sent home with 18 Fr Foleys catheter.

4. Abdominal distension

Patient had abdominal distension. Ascitic tap was done. He was taking vegetarian diet as advised in alternative medicine. His serum albumin was low. The patient and caregivers were educated regarding need for proteins in diet. He was advised the need to take mixed diet. He was informed that abdominal distension is part of the disease and that he may require tapping in future as well.

5. Financial constraints and Quality of life

He was from a lower middle-class family. In alternative medicine, he had expenditure of Rs.60,000 for 10 days in-patient treatment which he had to undergo every month for 6 months. This affected his family financially. He had to take strict vegetarian diet, while he always liked to eat fish and meat. He had to be admitted for 10 days every month and hence his son could not go for work as he had to stay with patient.

Current status of the patient.

Patient is now under treatment from Family Medicine department and he knows about the disease and its prognosis. He needs ascitic tap once every 2 weeks which is done as an outpatient procedure. His daily water intake is restricted to 2L/ day, salt intake is restricted to 2g/day. He is given Frusemide- Aldactone combination. He is not on Foleys catheter but is informed that he may need bladder wash if blood clots cause urinary obstruction. He is taking mixed diet. He is doing his routine activities on his own and visits church every Sunday. His son is going for work and taking care of finances at home.

Reference:

https://www.who.int/health-topics/palliative-care