DNR-IR

One of my favorite patients is in terminal liver failure in the ICU. It’s not clear to any of the experts on her subspecialty multidisciplinary team if this is from radiologically-occult infiltrative disease, the cumulative toxicities of multiple therapies (chemoembolization, radioembolization, peptide-receptor radiotherapy), or both. The sad thing is that she is dying slowly on a ventilator instead of peacefully at home. And that is partly my fault.

I met with the family multiple times as her downhill slide began. It is critical at this stage of the disease for the patient and family to recognize someone as the “captain of the ship” guiding the overall care plan. When I asked them, ‘who is your doctor?”, the answer was, “you are.”  I spoke at length with her husband and children, trying to lay out reasonable expectations regarding her grim prognosis in the face of strong denial. They were still asking about family-donated liver transplantation and doing aTIPS for her ascites as her total bilirubin soared from 25 to 40 mg/dl. Unfortunately, I was away lecturing at a cancer conference when she decompensated at home. The family panicked, brought her into the ICU and kept her a full code. All I could think as I heard the story unfold was, "where was her doctor?". He was me, and I was far away, with no surrogate.

It is a testimony to the growth of IO as the fourth pillar of cancer care that patients now recognize their interventional oncologist as “their cancer doctor”. Being the patient’s doctor carries additional responsibilities beyond consulting and perioperative care for ablating and embolizing tumors. It includes learning to give end-of-life counseling; providing resources for home hospice, visiting nurses and aides; lists of support groups; and having brochures and contact information for these agencies. Know the patient’s wishes – DNR status, Power of Attorney -- and make sure these decisions have been made and documented.

Know when to say no.  Avoid “DNR-IR”. Interventionalists cannot fix everything, even though we are often perceived as miracle-workers. Futility is a contraindication to therapy. Do what you should, not what you can. Patients with advanced cirrhosis (Childs C), deteriorated performance status (ECOG 3-4), or disseminated disease will not benefit form organ-directed image-guided therapy, except to palliate specific symptoms such as pain. 

Cancer patients do best when they have a team of caregivers. Sometimes the IO gets to be the captain of the team.

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