Reference no: EM133309532

Joe Murphy is a 58 year old male diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Two years ago he noticed a silvery patch on his tongue but did not immediately seek medical attention. He continued his pack a day smoking habit as well as chewing tobacco.

About six months ago Joe sought medical attention after he developed the following symptoms: a feeling that something was caught in his throat, difficulty chewing and swallowing, difficulty moving his tongue, difficulty articulating words and numbness of his tongue.

He was diagnosed with an oral squamous carcinoma on the anterior two thirds of his tongue and the floor of his mouth. It was found to have metastasised to his cervical lymph nodes. He immediately underwent a surgical resection of his tongue with extensive resection of bone and soft tissue.

Question 1 The malignancy progressed rapidly despite treatment, resulting in the following distressing symptoms:??????? the loss of his tongue made speech completely unintelligible, there was also ???????extensive loss of teeth making it very difficult to swallow, ???????severe facial disfigurement, ???????the necrotic non-healing oral ulcer caused severe mal-odour, as well as significant ???????facial pain.

At first, Mr Murphy's symptoms were relatively well controlled with:

Methadone (50 mg thrice daily),
immediate-release morphine sulfate (20 mg every four hours,) for breakthrough pain and, on an "as needed" basis,
haloperidol (0.5 mg every six hours) for nausea and vomiting,
lorazepam (0.5 mg every four hours) for anxiety,
Discuss why this combination of medication has been prescribed?

Question Two

Mr. Murphy did quite well on this regimen for several weeks, but as the disease progressed, his pain worsened culminating in admission to the hospital for symptom control. Upon admission, numerous interventions were attempted in an effort to ease Joe's pain, including:

conversion from oral methadone to a continuous subcutaneous infusion of morphine (6 mg/h)
patient controlled anesthesia (PCA) of morphine sulfate infusion 2 mg every 15 minutes as needed
lorazepam (0.5mg every 4 hours);
metronidazole gel applied to the ulcerated tissue on the face
oxygen via a nasal cannula; and
a fan gently blowing on his face.
Unfortunately, none of the treatments alleviated or attenuated his sense of severe pain.

Consider the changes made to the medication regime - what was the rationale for these changes?

Question Three

Over the next week, Joe's pain worsened despite aggressive pain management. He was clearly suffering greatly and this caused severe distress to his family who could not bear to see him suffer in this manner.??????? Since his pain was unendurable and refractory to all palliative measures, palliative sedation was proposed as a humane and compassionate approach to allay his suffering.

???????After explanation of the procedure, both he and his family readily agreed to deep and continuous palliative sedation. An informed consent document was signed and a note describing the indications and plans for palliative sedation was recorded in the patient's chart.

A 4-mg subcutaneous bolus of midazolam was then administered, followed by a continuous subcutaneous infusion of 1.5 mg of midazolam per hour. The Ramsay Sedation Scale was used to monitor depth of sedation, and the dosage of midazolam was titrated upward to maintain a deep level of sedation (a 4-mg bolus every 30-60 minutes, as needed, was used, with the continuous infusion increased by 0.5 mg/h after each bolus).
He was sedated within 10 minutes, but after 30 minutes he was still rousable with verbal stimulation and complained of pain. So a second bolus of midazolam was administered and his infusion increased to 2 mg/h.
Titration continued over the next few hours until he was deeply sedated, with an eventual dose of 5 mg/h required to maintain deep and continuous sedation.