Monday, May 26, 2008

Denying the Obvious: How to Approach Patients
Who Delay Medical Care for Advanced Breast Cancer

Pallimed Case Conferences ( is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
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By Winifred G. Teuteberg, MD
Vol 8, No. 2 - March 2008
(Original PDF)

MM is a 77-year-old woman who presented to the emergency department with flu-like symptoms. On exam she had a large palpable mass in her left breast. A CT scan revealed a 10cm left breast mass and liver and lung metastases. After admission to the hospital, the breast mass was biopsied. The consulting oncologist met with MM and told her that she most certainly had metastatic breast cancer, although the biopsy results were not yet available. The primary service asked palliative care to see MM because of her advanced disease. There was also concern that she did not understand her diagnosis.

I came into the patient’s room and introduced myself, saying, “I see many of the breast cancer patients on this floor.” The patient stopped me, saying, “I don’t have cancer.” I apologized and asked if I might sit down and talk with her. I asked her to explain what she understood of her illness. She said she had fallen several months before and bruised her left breast. It had been sore ever since but she was otherwise fine until she developed “flu” and came to the emergency department. She understood that a scan showed “something in my liver,” but believed that without the biopsy she did not have cancer.
I explained that her doctors were concerned she had cancer. I then asked her what she was most worried about. She told me that her husband died from lung cancer the year before after a two-year battle with the disease. She said, “I’m afraid I’ll suffer the way he did with chemotherapy and radiation and die anyway.” I counseled her that some patients with metastatic breast cancer choose to focus on comfort, rather than pursue aggressive therapies that may not help them achieve more quality time. She was relieved to hear that this was possible. She was discharged with a plan to discuss treatment options with her oncologist but was also considering referral to hospice.
A large part of my clinical practice involves providing inpatient palliative care consults to breast cancer patients. During my three years of practice in this setting, I frequently encounter women presenting with palpable, often fungating, breast masses. In nearly all of these cases patients sought medical attention for a symptom not obviously related to the mass or at the request of a concerned friend or family member. Even after being told their diagnosis, patients often did not accept it and continued to believe their symptoms were related to something else. They can continue in this belief for months and sometimes years. When other health care providers encounter these patients, they are struck by the magnitude of their denial.
Upon review of the literature, denial of obvious breast cancer and delay in presentation for medical care is quite common. Approximately one third of patients present for evaluation more than 12 weeks after developing symptoms and about 5% present more than a year after noticeable symptoms. Most of these patients present with locally advanced or metastatic disease. Studies identify several reasons for this delay, most of them related to the patients’ initial psychological response to their symptoms. Patients who delayed presentation were more likely to have significant fear of cancer itself and/or therapies for cancer including disfiguring surgery. Many patients noticed a lump but believed that the lump would go away or attributed it to another cause. Others did not know that breast cancer is a potentially curable illness and fatalistically did not seek treatment because they believed they were going to die no matter what they did. In several studies patients reported that they knew the symptom was serious, but were too busy caring for others such as young children or sick family members to take time to seek medical advice.
Interestingly, although some studies found a small increased incidence of psychiatric illness in patients who delayed presentation, studies found no significant differences in psychological well-being between patients with early versus late presentation.
When caring for such patients, it is important to realize that their reasons for delaying presentation or even acknowledging their illness are significant for them. Rather than initially attempting to change their beliefs and force them to accept their diagnosis, it is best to first explore their fears and identify ways to help allay these fears. In the case of MM, her fear was that she would suffer the way her husband did and die anyway. Although I was not able to cure her cancer, I was able to provide comfort by offering her a way to avoid the suffering that her husband endured.
1. Phelan M, Dobbs J, David AS. ‘I thought it would go away’: patient denial in breast cancer. J R Soc Med 1992;85;206-207. Full PDF
2. Mohamed IE, Williams KS, Tamburrino MB, et al. Understanding locally advanced breast cancer: What influences a woman’s decision to delay treatment? Preventive Medicine 2005;41:399-405. 10.1016/j.ypmed.2004.12.012 [doi]
3. Burgess CC, Potts HWW, Hamed H, et al. Why do older women delay presentation with breast cancer symptoms? Psycho-Oncology 2006;15:962-968. 10.1002/pon.1030 [doi]

Monday, May 26, 2008 by Christian Sinclair ·

Monday, May 12, 2008

What Is That Guy Thinking?
When the Attending Is the Person Who Needs the Intervention.

Pallimed Case Conferences ( is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
For active posts on these cases and new cases go to 

By Elizabeth Chaitin, MSW, MA, DHCE
Vol 8, No. 1 - February 2008
(Original PDF)
Mr. James Martin is 74-year-old man admitted to an outside hospital with a two-month history of shortness of breath, edema, and recent difficulty ambulating. He has a history of an aortic aneurysm, hypertension, cellulitis of his lower extremities, chronic obstructive pulmonary disease from years of heavy smoking, as well as ischemic cardiomyopathy and congestive heart failure. Mr. Martin had worsening renal functioning upon admission and was found to have two masses, one on each adrenal gland. He was scheduled for surgery and an ethics consult was called because the patient “didn’t seem mentally right.” The ethics consultant interviewed the patient and family and discovered that Mr. Martin was “mentally slow” and was illiterate. He never attended school and was raised and cared for by family until his adult years when he rented a small apartment near his sister Debbie with whom he is quite close. The consultant recommended that his sister sign for consent for the surgery for she felt Mr. Martin was neither able to comprehend the severe nature of his current condition nor could he comprehend the risks undertaken with the recommended surgery. The sister consented to bilateral adrenalectomies.
In the weeks following this surgery, the patient seemed to continue to decline, and his sister expressed concern that “James was suffering.” Six weeks after surgery the consultant believed that the patient was dying and spoke consultant believed that the patient was dying and spoke with the attending physician who responded, “don’t throw in the towel yet” and recommended feeding tube placement in the hope that the patient would improve over time.
The ethics consultant requested a palliative care consult for the purposes of gaining perspective on prognosis. Both the palliative care physician and CRNP felt the patient was, in fact, actively dying, and recommendations were made for his comfort. Rather than taking a hard stand, over the next week, the team regularly communicated with the attending service, and eventually the focus of care changed to comfort measures only. Mr. Martin was discharged to an in-patient hospice close to his sister and died four days after discharge.
In this case there were two different stories or viewpoints present, which could have been conflictual in nature depending on the approach taken by the Palliative Care and Ethics Team. In Story One, the attending believed strongly that it was possible the patient could “get well” with more time and encouraged the family to consider the placement of a feeding tube. In Story Two, the Palliative Care and Ethics Team was certain that the patient was dying and believed that the placement of a feeding tube would not add to the longevity or quality of the patient’s life.
The approach the Palliative Care and Ethics Team chose was to focus their discussion on acknowledging the attending’s viewpoint and clearly communicating their understanding of his dedication to his patient, rather than choosing to register their disagreement with his viewpoint. As a result emotions did not get in the way of the communication between the two parties (Fisher, Ury & Patton 1991). The team assumed that the attending had good intentions toward his patient. Their goal was not to convince the attending he was mistaken in his viewpoint but more to suggest a reevaluation from their perspective. It was the ability of the attending to consider both viewpoints, which allowed him to re-evaluate his perspective regarding the patient’s ultimate prognosis (Stone, Patton & Heen, 1999).
The approach taken by the Palliative Care and Ethics Team was not one of confrontation, but more one of soft negotiation through which the attending could be free to see and accept a different perspective without any loss of self-esteem or pride. Stone, Patton and Heen describe such an approach as working through different conversations in an effort to see what is at the basis of apparent conflict or disagreement. This perspective moves one toward understanding of different perspectives and their associated emotions. In addition, they note, “this approach will help you become more aware of the process of communication and gain insight into what’s making your conversations difficult” (Stone, Patton and Heen, 1999).
(Edit: (6/16) Added missing fragment "...consultant believed that the patient was dying and spoke with...)

Monday, May 12, 2008 by Christian Sinclair ·

Using Online Cases for A Medical Training Program

Pallimed Case Conferences ( is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
For active posts on these cases and new cases go to 

First of all, the cases shared here are from the wonderful resource at the University of Pittsburgh - Institute to Enhance Palliative Care (Bob Arnold, David Barnard).

One potential way to add case conferences to your fellowship program is to have your fellows post comments online about the cases. If the fellowship director reads the cases, comments and keeps up to date on the comments (via email notification), you now have a case conference series with documented involvement (the comments) without much production and effort. If you already have a case conference this could augment it, but by no means should it replace it.

As far as following your fellows comments, since the site is public, they have the option of posting openly or anonymously. I would encourage thoughtful open comments, since anonymous can allow civility to be checked at the door occasionally, but I understand the issues of liability for words as a physician when posted online. So if you really wanted your fellows to participate but they (or you) wanted them to stay semi-anonymous, have them pick a screen name that only you know, so you can track their comments to give credit for the participation. Now you should all know that nothing is truly anonymous on the internet, so they should still choose their words carefully.

If you decide to use this as part of your program, please email me and let me know, or post it in the comments on this thread.

by Christian Sinclair ·

Sunday, May 11, 2008


Welcome to Pallimed: Case Conferences


Founded: April 11, 2008

We are glad you found us and hope you enjoy the information and commentary we provide. If you are here we presume you have a basic understanding of the field of hospice and palliative medicine, and are likely part of the professional field. (Here is a good description of palliative medicine).

Pallimed: Case Conferences is a companion blog to Pallimed: A Hospice and Palliative Medicine Blog. Some readers have asked that Pallimed include cases for discussion of difficult and interesting situations in palliative medicine. We agree this is an important way to learn and decided to include it as a separate blog since it might appeal to a particular subset of readers. The cases presented have been reformatted with permission from David Barnard, JD, PhD from the University of Pittsburgh Medical Center Institute to Enhance Palliative Care.

Our target audience is the professionals (MD, DO, RN, LPN, LVN, Home Health Aide, ARNP, SW, Chaplain, Administrators, PT, OT, Speech, Pharmacy, etc.) working in hospice & palliative medicine, but we welcome all readers to this blog, including patients, families and other medical professionals outside of this field.

Our goal is to review current palliative medicine, hospice, end-of-life research with a particular focus on publications not from the major palliative care journals. We also highlight important events in end-of-life care from the news media and entertainment arenas. Pallimed: Case Conferences is not intended to replace the patient-physician relationship.

Who is Pallimed: Case Conferences?

Drew Rosielle, MD
Pallimed Editor-in-Chief

Christian Sinclair, MD
Pallimed: Case Conference Section Editor

Click here if you want to know more about us.

You, the readers!

Please email Drew or Christian to give us general feedback on the site.

What About Your Day Jobs?

We do this in our spare time, for fun and for the pursuit of knowledge and truth (sounds noble!). We have a standard disclaimer that the views we express here do not represent the views of our employers or former employers or institutions that we are affiliated with. Please see the disclaimer and copyright information at the very bottom of our homepage. Our effort here is not to provoke but to inform and have open conversation about some potentially thorny issues. Our clinical care is enhanced by being able to comprehend as much information in our field as possible, which is part of the reason we do this blog. We use our real names and not pseudonyms, because we feel it imparts credibility and responsibility for our words.

How To Make Pallimed: Case Conferences Work For You!

So what is the big deal about these blogs I hear so much about? If you are new to blogs the first thing to do is 'bookmark'/'add to favorites' this site in your browser (Ctrl+D in most browsers). You can even add the bookmark to your toolbars in your browser (Firefox, Internet Explorer) so that you can access Pallimed: Case Conferences with one click. This is a great start, but the main problem is you have to actively seek the site to get the information. Wouldn't it be nice if the information just came to you?

To get the information to come to you we hav
e a two different options to subscribe to Pallimed: Case Conferences:

1) Email

Using a service called 'Feedblitz', Pallimed: Case Conferences can provide you with posts as they are written directly to your email box. Just type in your email and click the button and you are done. No signing up for a new account or anything. Give this a try and if it does not work for you then just unsubscribe.

2) RSS/Atom Feeds

If you are a little more tech savvy you can make use of the RSS/Atom feature present on most blogs or news sites. RSS (Really Simple Syndication) and Atom are very similar. You may be familiar with the orange button on many sites that looks like this:

or the icon that looks like this:

Here is a very helpful 3 minute video to explain RSS.

Basically RSS and Atom are computer languages for universal formating of information. It can be read using a RSS/Atom Reader. Many readers exist as separate programs or add-ons to your browser, but you can use Firefox 2.0, Safari or Internet Explorer 7 to do the same thing (links go to those sites tutorials). Those of you on IE6 need to upgrade to IE7 to get the RSS benefit.

Ours is located in the right column and is supported via Feedburner. If you click on this link it will take you to their site to pick your feed options.

Christian recommends Google Reader (especially if you have a Gmail account). It is very intuitive as are most other RSS readers. If all this talk scares you, it really is not that bad, just try it. You will not break your computer.

3) The cases

The cases are graciously shared from the University of Pittsburgh Medical Center's Institute to Enhance Palliative Care. David Barnard, JD, PhD and Bob Arnold, MD have agreed to reformat the IEPC's monthly cases series to open a wider discussion on Pallimed: Case Conferences.

4) Navigating Pallimed

We have a search bar located at the very upper left of the screen in the Blogger Toolbar.

Each post/case is labeled by common topics we cover here at Pallimed so you can quickly find other similar posts. On the left hand column you will also find a list of labels and the number of posts) Click on a link and see what you find! Many older posts do not yet have labels. These labels do not translate to posts on other Pallimed blogs (Pallimed or Pallimed Arts & Humanitites)

Also in the left hand column is a feature from Google reader that allows us to share Hospice & Palliative Medicine related stories that come across our desk, but are not so interesting that we feel compelled to write about it.

In the right hand column we also have a link to the Pallimed Archives (where you can browse blog posts by date).

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Pallimed has a comment function (at the bottom of each post) that allows you to comment on each post. Just click on the "comments" link at the end of each post (the link usually tells you how many comments have been left so it says, e.g., "0 Comments" or "1 Comment"). Tell us your opinions and thoughts. This can be a great community for discussion. You can even add comments anonymously, especially if you want to say something controversial. Even something as pithy as 'great post' or 'what are you talking about?' helps us to keep working at the blog day in and day out for you.

We ask that you refrain from providing specific details about your own cases because of HIPAA restrictions. We strongly encourage you to change any minor details or talk about issues in the case in broader terms. We strongly encourage no discussion of exact prescribing information or giving or soliciting medical advice on Pallimed: Case Conferences. If you are not sure what you should write, please choose something more conservative.

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Feel free to email us directly at our emails listed above. Subscribers (via RSS or email) are kept private and the information will not be distributed or accessible to anyone but Drew or Christian. Website stats for visitors are tracked by Google Analytics, but no identifiable information is kept which could identify a user. Pallimed uses 'cookies' to track returning visitors, but again this data will not identify a individual user, nor is it kept over time.

Sunday, May 11, 2008 by Christian Sinclair ·