Likely metastatic gastric cancer, ? futile procedure

88yo lady for repeat gastroscopy for confirmation of (suspected) gastric cancer.

Background

  • ? Metastatic gastric adenocarcinoma
    • Weight loss ~30kg
    • Nausea, anorexia, abdominal pain.
    • CT abdo shows a thickened gastric wall suspicious for malignancy, with widespread lymph nodes and a peritoneal lesion suspicious for metastatic disease.
    • Gastroscopy April – large ulcer seen (H. Pylori +). Suspicious for malignancy but not found on histology/cytology.
    • Delirium lasting ~1/7 after gastroscopy.
  • PEs – bilateral, diagnosed ~3wks ago. On therapeutic clexane.
  • CKD + recent AKI, without return to baseline.
  • Moderate aortic stenosis  2016
  • Frail. Family assisting with all ADLs and using 4WW as wheelchair for most distances.
  • Multiple recent ED presentations and hospital admissions with pain.

Issues

  • What are the goals of care?
    • The patient seems to be dying, with symptoms and imaging consistent with metastatic gastric adenocarcinoma. Surgical team agrees this is the most likely diagnosis.
    • Surgeon says a formal cancer diagnosis would not lead to active treatment (chemo/surgery) due to her advanced age and frailty
    • Palliative radiotherapy might be considered if bleeding became an issue (not currently an issue).
    • Surgeon said that a diagnosis would assist with prognostication, dictating fast track palliative care v. Nursing home care for this lady.
    • Patient + family unaware that no active treatment was being considered.
    • Patient + family’s main priority was for symptom relief, which they were worried they needed a formal diagnosis to receive through pall care.
    • Concerns about deterioration after even a short procedure, given her frailty/active PEs/recent delirium, significantly reducing the length or quality of her remaining life.
    • GP very happy to manage this patient’s symptoms with palliative care in the community, although noted that pall care services are in her opinion, fairly limited.

Discussion

  • Should the gastroscopy proceed?
    • Group consensus was that this is low yield healthcare as it provided no material change to her treatment plan.
    • Discussed the need for anaesthetists to see themselves not as technicians, providing services to proceduralists indiscriminately, but as active parts of the patient’s perioperative journey, with the ability to oversee/question/add value to the process.
    • Review booked with surgeon in 1/12.
  • Midazolam use in the elderly – ? Contributes to delirium after endoscopic procedures.
    • Frequent use in large doses by procedural seditionists to minimise airway and haemodynamic complications.
    • ? The specific contribution of midazolam to delirium in elderly patients beyond that of change in environment, fasting, dehydration, surgical insult, pain, other anaesthetic agents, analgesics, acute illness, etc.
    • A recent small, prospective, observational pilot cohort study screened for delirium using the CAM tool in 40 patients who underwent elective endoscopic procedures. No patients were found to have delirium at 24-48h post procedure. https://doi.org/10.1186/s12871-021-01275-z