Despite advances in technology and science, many people diagnosed with cancer are likely to die from the disease. Because of the long-term relationships that oncology nurses develop with patients and their families during lengthy treatment periods, they are the most appropriate clinicians to provide care across the continuum and through the final journey. Care of patients in the final days of life requires a comprehensive knowledge of common syndromes, skillful assessment, and adept clinical management. Nurses cannot focus solely on the needs of patients; family members often are unaware of the dying process. Oncology nurses are uniquely qualified to provide education and support to families at the bedside witnessing the final days and hours of their loved ones. Finally, oncology nurses involved in the care of dying patients are at risk for burnout and need to provide care for their own needs to find balance between their professional and personal lives.

Life's final journey: the oncology nurse's role.

Status epilepticus remains a life-threatening condition that afflicts both adults and children which although occurs in patients with epilepsy, often presents as new-onset seizure activity also. Refractory status epilepticus poses a management challenge for neurological and neurosurgical teams. Subdural grid electrodes were used to record cortical discharges and guide tumor resection involving eloquent cortex and multiple subpial transections in a 48-year-old man with left hemiparesis in status epilepticus. He had been refractory to multiple medical therapies in persistent epilepsia partialis continua for a prolonged period. As an alternative to higher-dose suppressive medical therapy, the patient elected to proceed with subdural grid mapping after seizure semiology (“negative” scalp electroencephalogram) localized the seizure focus to the right hemisphere, motor cortex. Following tumor removal, multiple subpial transections were subsequently performed over large areas of the motor and sensory strips and successfully resolved the status epilepticus. The patient made an excellent recovery, became seizure free, had improved left-sided strength and was discharged home shortly after. This case illustrates a potentially life-saving technique for the treatment of refractory status epilepticus. Multiple subpial transections and other neurosurgical intervention should be considered for patients with status epilepticus. When localization with surface electrodes is poor, especially in eloquent cortex, subdural grid recording can be used to direct focal resection and/or multiple subpial transections to minimize neurological deficits. A review and summary of previously published neurosurgery cases for status epilepticus is discussed.

The role of neurosurgery in status epilepticus.

No consensus guidelines exist for the treatment of refractory myoclonic status epilepticus or refractory myoclonus in the palliative care setting. Evidence-based guidelines for the general medical population are often neither practical nor applicable at the end of life. Many challenges, including medication availability, route of administration, monitoring, and work-up are all unique to the palliative care setting. Two patients with refractory myoclonus versus refractory myoclonic status epilepticus are described here, illustrating the challenges involved in treatment as well the need for further research for therapy in the palliative care setting.

Management of refractory status epilepticus in an actively dying patient.

Antiepileptic medication use in noncancer hospice/palliative care patients is not well defined. The authors report the case of a human immunodeficiency virus (HIV) patient under hospice care with increased seizure frequency. The patient is a 22-year-old female with advanced HIV disease complicated by tonic-clonic seizures, hypoalbuminemia, gastroesophageal reflux disease (GERD), and gastritis. During an admission to the hospice inpatient unit, she developed increasing seizure frequency while receiving oral phenytoin. After collaboration between the clinical pharmacist and the hospice treating physician, they simplified her medication regimen, discontinued the phenytoin, and initiated oral levetiracetam. After these adjustments to her medication regimen, the patient's seizure frequency decreased significantly. This case illustrates the challenges of anticonvulsant use in advanced disease, including drug-drug interactions, impaired pharmacokinetics parameters, and increased risk of adverse effects. The importance of continuously monitoring patients for adverse drug events and assessing patient specific factors to help guide medication selection are also highlighted.

Seizure management in a complex hospice patient.

„Die Pflege eines Sterbenden muss zuallererst seine physischen Bedurfnisse Berucksichtigen“. (Kubler-Ross 2000)

Symptomerfassung und -therapie

A31-YEAR-OLD COMPUTER CONSULTANT was admitted to the hospital for intractable nausea and vomiting. He had presented 18 months earlier with a perforated bowel after a long history of Crohn’s disease. At surgical exploration he was found to have a perforated appendiceal cancer with omental and peritoneal metastases treated with a right hemicolectomy and diverting ileostomy. He received systemic chemotherapy and experienced stable disease, as well as an excellent performance status, for approximately 15 months. He then developed small bowel obstruction caused by diffuse peritoneal carcinomatosis that was treated with a venting gastrostomy tube and nutrition support with total parenteral nutrition. Abdominal pain was treated with intravenous hydromorphone 26 mg/hr with 26 mg every 15 minutes as needed. He experienced nausea and vomiting treated with lorazepam (Ativan, Wyeth Pharmaceuticals, Collegeville, PA), dolasetron (Anzemet, Hoechst Marion Roussel, Bridgewater, NJ), and promethazine (Phenergan, Wyeth Pharmaceuticals). Other medications included pantoprazole (Protonix, Wyeth-Ayerst, Madison, NJ), nystatin, and zolpidem (Ambien, Sanofi-Synthelabo, Inc., New York, NY). He was admitted to the oncology unit of an acute care hospital for management of intractable vomiting. Several hours after admission he developed myoclonus, hyperreflexia, agitation, delirium, and eventually, tonic-clonic seizures. An initial intravenous loading dose of phenytoin (Dilantin, Pfizer, Toronto, Ontario, Canada) 1 g followed by a 200 mg intravenous bolus every 12 hours did not stop the seizures, nor did valproate sodium (Depacon, Abbott Pharmaceuticals, Abbott Park, IL) 500 mg intravenous infusion every 12 hours, chlorpromazine (Thorazine, SmithKline Beecham, Cambridge, U.K.) 25 mg slow intravenous push every 6 hours, lorazepam 2 mg intravenous every 2 hours, and diazepam 5 mg every 5–10 minutes. Despite these medications, and a reduction in the hydromorphone dose by 50% to 13 mg/hr and discontinuation of the bolus dose, the generalized tonic-clonic movements increased in intensity and frequency (every 8 to 10 minutes) to status epilepticus. The patient remained arousable, following simple commands, yet was disoriented. Evaluation revealed acute obstructive renal failure (blood urea nitrogen [BUN] 37 mg/dL, creatinine 4.2 mg/dL) secondary to diffuse carcinomatosis. The family’s goals were to keep the patient comfortable.

Refractory status epilepticus.

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Refractory status epilepticus.