← The Curbsiders Internal Medicine Podcast
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- [00:00]
A
Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool stuff@patreon.com curbsiders.
- [00:20]
B
Meredith Moni, we're in Nashville. We are, I don't know, thinking about going to a concert. Little worried there's going to be an obstructed view.
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C
Ba da dum bum.
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B
So bad.
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D
Okay,
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E
the Curbsiders podcast is for entertainment, education and information purposes only. And the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're welcome.
- [01:04]
B
And welcome back to the curbsiders. I'm Dr. Moni Amin, joined by my eternally effervescent co host, Dr. Meredith Trubitt. How are you this day? Situation Afternoon.
- [01:15]
C
We are in the afternoon. I'm doing well. How are you?
- [01:18]
B
You know, I am awake and caffeinated, sort of. It's a great feeling.
- [01:23]
C
That's all you can say. And we have our nerds.
- [01:24]
B
We do have our juicy gummy cluster nerds. And on tonight's show, we're gonna discuss kind of a potpourri of cancer related topics. Malignant smile, bowel obstruction, cancer associated thrombosis, and just those difficult conversations that you have in patients with advanced cancer. And we have a great guest, Dr. Jensen Morris, who Meredith's gonna tell you a little bit about here in a minute. But before we do that, will you please remind the good people in the audience what it is we do on this show?
- [01:52]
C
I'd love to. We are the Internal Medicine Podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. And like you already said today, tonight, whenever you're listening to this, we have our guest, Jensen Morris, who completed her undergraduate degree at Princeton University. She went to medical school at Mount Sinai School of Medicine and finished her internal medicine training at the Brigham and Women's Hospital. She specialized in the care of hospitalized patients and and now leads the Smilo Hospital Service dedicated to the care of hospitalized patients with cancer. She has a strong interest in quality improvement, education and team building on the inpatient medical service. And as you already said, we'll be talking a little bit about some very, I think, high yield specific cases for our patients with advanced cancer. So without further ado, a reminder that
- [02:42]
B
this and most episodes will be available for CME credit through VCU Health at curbsiders.vcohealth.org foreign we're gonna do a lightning round here. First thing, would you mind telling us a little bit about something you like to do outside of medicine?
- [03:02]
D
I love to play tennis. Absolutely. I love everything about tennis. I watch even the minor tournaments. Sometimes I even watch the Yale players play locally. Actually recently had major orthopedic surgery, so I'm laid off from tennis for a while.
- [03:19]
B
That's unfortunate.
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D
Yeah.
- [03:20]
B
So I feel like I know the answer to this. But you fall aware on the pickleball tennis debate.
- [03:27]
D
I think that's a really important question. In fact, if you have time, we could probably devote a podcast to that. Yeah, I mean there's a lot to be said, but do I have to answer it for real?
- [03:38]
B
No. No. I feel like that debate has already been settled.
- [03:43]
C
So on that note, I'm assuming the major orthopedic surgery was not related to pickleball and we'll switch topics. Tell us about some meaningful advice or feedback that you have gotten before.
- [03:56]
D
I love this question. I remember exactly where I was. It was maybe second or third year of med school. We were having a professional development discussion with in my case, I was in a small group with a senior surgeon, a woman who was a full professor and a surgeon. And after she gave her spiel someone said, how do you do it all? And she said, well, the days of doing it all, the triple threat, are over. You really can't be the master clinician, the educator and the NIH funded researcher that that doesn't exist anymore. But you can do it all, just not at the same time. Your career is long. You can teach, you can do research, you can be a clinician just over the course of your career. And so that's the best advice I give the younger doctors who come to me. I say there's time for everything and there's also time to raise a family and do all the other stuff you love.
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C
That is good advice and I have never heard it until now and wish I had heard it when I was in school.
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B
Yeah, that's a good tone setter for your career to hear that so early
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C
because otherwise I think definitely can come in feeling like you are trying to Just say yes to everything and you don't have to.
- [05:13]
D
And, you know, I think the second part of that advice, which is my added on part, is I tell young doctors, focus first on becoming a really good doctor, because that sets the stage for everything else you want to do in your career. So take care of lots of patients.
- [05:29]
C
Yep. The foundation of being a good clinician cannot be set enough. And I think it's reason why we do this podcast.
- [05:36]
B
Indeed, in a lot of ways. Meredith Picks of the week.
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C
Sure. You want me to go first?
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B
Please.
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C
So we're now, I guess, technically on day two here in Nashville, and you, me, Caroline, who's not on the camera. Cause that's where she prefers to be. All went to dinner last night. We. It's March Madness. We tried to go to a women's only sports bar to watch basketball. Little did we know the the place is called chapstick. It looked like a fun vibe. Little did we know it was the first day of the kickball league for the LGBT community group that comes there afterwards. And they also had multiple activities going on at the same time. So it was. It was lively. More lively than what we needed to set the stage before this conference. But we had a great time. We then hung out there, took all of that in, did not speak to each other because we couldn't hear each other. And then we took our old feeble bodies to a pizza place around the corner where we could actually have a conversation. We had a nice time hanging out. So that's my pick.
- [06:47]
B
And you actually left out the best part, which was our tour to dessert that followed.
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C
Oh, I did leave that part out.
- [06:53]
B
And that is my pick of the week. Because you didn't do it. Thank God. Because I was kind of scrapped for what I was going to do, we went. So assembly food hall is phenomenal. The food is really good. We had already done lunch there, and then we went back because we saw there were like six dessert spots, and we went to three of them and did a dessert potluck. And it was fantastic. And I think we decided the cookie dough was probably the winner for the first round.
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C
It was with I think the crepe being second and surprisingly, the ice cream being the lowest one.
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B
Yeah.
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C
So highly recommend for desserts and other food, too.
- [07:29]
B
All the foods, really, but also dessert. I mean, like I said, there were six spots. So I feel like there's going to be another dessert potluck here soon. And now that I'm sufficiently hungry and feeling like the snacks that we had before we Started are starting to fade already. We are going to rush over to Cashel and get to our first case. Mr. Colin Block is a 60 year old man with known metastatic colorectal cancer involving the liver and peritoneum. Presents with four days of progressive nausea, vomiting, abdominal distension and an inability to tolerate PO intake. He reports crampy abdominal pain and that his last bowel movement was three days ago with minimal passage of flatus. Since then he's denying any fevers or hematochezia. His vitals are notable for just being mildly tachycardic with a heart rate of 102, but everything else looks fairly stable. He appears uncomfortable but alert. His abdomen is distended with diffuse mild tenderness and high pitched bowel sounds without parent needle signs. Labs notable for a white count of 11.8, hemoglobin 10.6, creatinine 1.2, lactate 1.4 Connecticut abdomen and pelvis with IV contrast demonstrates peritoneal carcinomatosis, moderate ascites and multiple diluted loops of small bowel with the transition point in the distal ileum consistent with a malignant small bowel obstruction. Jensa. Clearly he's obstructed. But I'm curious. Definitions are always a good place to start. How do you define a malignant bowel obstruction?
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D
It's actually an important question with maybe not such a clear answer. So good, good to sort of set the stage here. Technically the definition of a malignant bowel obstruction is obstruction anywhere from ligament of trites all the way down. It could include a gastric outlet obstruction from a pancreatic mass that's eroding through. It could include small bowel obstruction from radiation enteritis with strictures. It could include a colonic mass that is obstructing. So it's really broad differential. But then if you further read the literature there, it's kind of in most cases when people talk about malignant bowel obstructions, we're really talking about small bowel obstruction in the setting of widely metastatic abdominal cancer where with peritoneal carcinomatosis. And the reason we narrow it to that very focused definition is because you can imagine the prognosis for someone who comes in with a colonic obstruction from a new presentation with colon cancer who's potentially resectable and curative intent is totally different from someone who has an erosive mass in their duodenum. So I think it is really important, I think for the, for the, for this conversation. I think it's just much More informative for the listeners if we really narrow it to those with the diffuse metastatic abdominal disease.
- [10:25]
B
And presumably it's the CT scan findings of peritoneal carcinomatosis that help you differentiate between, like, malignant versus maybe, like, adhesive small bowel obstruction.
- [10:37]
D
Yes, I think probably in some cases, there's probably some overlap in the findings. I do think that there are some characteristics of malignant small bowel obstruction that are pretty telling. You know, one is, of course, there's peritoneal carcinomatosis. There's usually ascites. Often it's multifocal obstruction, which is unique. And with adhesions, it's usually a single focus. The other thing that's interesting is these patients often present with this very chronic yellow presentation where they tell you that they've actually been vomiting after meals for the last two weeks. I feel fine after I vomit, but it's been going on, and sometimes it's horrible, the pain, and sometimes it's not so horrible. Whereas my impression is those who present with an acute small bowel obstruction from, say, adhesions or another etiology tends to be an acute event, whereas this tends not to be.
- [11:32]
C
And so for Mr. Block, coming in with what we are going to call this malignant bowel obstruction. Now, what are your kind of initial priorities in when you're admitting him?
- [11:45]
D
I know this is going to sound obvious, but I think it's worth saying the most important priority here is for him to feel better. Now, of course, you're going to say, well, that's the same for every patient, but truly, I think we can get so caught up in perhaps. I'm calling oncology. I'm calling surgical oncology. I'm getting the NG tube. I'm doing all this other stuff that perhaps we forget that actually the priority priority here is to make Mr. Block feel better. And how are we going to make him feel better? A couple liters of IV fluids. I think any hospitalist knows people feel a whole lot better with a little bit of IV fluids. Then, you know, opioids. I know we, you know, we worry about giving opioids in the setting of obstruction. Maybe it's going to worsen their ileus, but they need opioids. And then also just remember to account for their chronic opioid use. You know, a lot of cancer patients are already on high doses, so make sure you're dosing it appropriately. So fluids, opioids, antiemetics. We can talk more about NG tubes, we can talk about prognosis, but I Do want to just slide in here that while I'm giving their IV fluids and their opioids, I'm having a nice conversation and we're chatting and we're just want to get an idea of where they are with their cancer. What's their understanding, what has their oncologist said to them? Where are we with this? It's amazing. Just, this isn't a goals of care conversation. This is just a chat. And some people will say, look, I'm only doing this chemotherapy for my daughter. I am done. I know, I know, I'm dying. And then the patient in the next room who has the exact same diagnosis will say, oh, oh my gosh, am I gonna be out of the hospital by Tuesday? I have an appointment with clinical trials on Tuesday. I've gotta be out of the hospital. And so these are kind of just like sussing it out early on, I think is really important to do.
- [13:47]
C
I wanna go back to a couple of things. So first, for the opiates, like you said, a lot of these patients are on a chronic regimen.
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D
Yep.
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C
So when they're coming in with, like you said, the pain can kind of be variable throughout. Is your goal usually to just kind of start them on what their home like regimens are and up, titrate there as needed or what. What's kind of your philosophy on how you do the opiate dosing?
- [14:10]
D
Yes. So in many cases I invite my friends from palliative care to help me out. Let's just start right there. But on the initial, just initial dosing, I do have to make sure that I have transitioned all their home oral meds to an IV formulation because clearly at this point we're on bowel rest and so I have to make sure I give them equivalent. And then I usually do some kind of sliding scale, mild, moderate, severe pain, where I'm really doubling their home PRN dosing in the IV formulation for their severe pain.
- [14:47]
C
And then on the same token, because we're often talking about like a GI cancer population, how do you kind of make manage the antiemetics too? Do you schedule? Do you just peer in? How do you do that?
- [15:02]
D
Yeah. So antiemetics is actually kind of a whole conversation unto itself because in these patients there are actually guidelines like nccn, our major cancer guideline group, has guidelines on management of malignant bowel obstruction. And the antimedics that we commonly use, like, I know my go to is ondansetron or perhaps that other one that starts with a C, but I think I'm Supposed to call it pro chlorperazine. Those would be my go to antiemetics, just in general, but actually in this population, those actually aren't your go to. Your go to antiemetics are actually if it's a partial small bowel obstruction, metoclopramide, you don't want to use a promotility agent. Of course, if it's a full, and I have to say, like in general, using a motility agent in these patients makes me a little nervous because maybe it's a partial right now, but tomorrow it's a full but you know, a complete bowel obstruction. That makes me nervous. But then we're looking at antisecretory agent. And the antisecretory agent that we want is octreotide. Actually, which I tell you, before I was an oncology hospitalist, I'm pretty sure I really didn't use octreotide at all. Octreotide, we can dose iv, it's three times a day. It's better than scopolamine in terms of antisecretory agent. And then actually the other agents we use are olanzapine and haloperidol. Those are your go tos for bowel obstruction. For antiemetics.
- [16:43]
A
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- [19:34]
C
Perfect. Um, and then my last question is around the NG tube.
- [19:39]
D
Ah yes.
- [19:41]
C
In the situations I've been in managing malignant bowel obstruction, I feel like there ends up always, always being some sort of goals of care conversation almost around the NG tube. Oh, and I'm wondering how you like present the information. How do you. Because in the immediate certainly we make them feel better but like you've already said, yeah, you can have someone who is, you've sussed it out. They're full, full steam ahead. And others are like I am not full steam ahead.
- [20:08]
D
Yeah.
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C
So I'm wondering how you manage this.
- [20:11]
D
So I think your your question is actually is pretty interesting for two different reasons. One is around the goals of care part and an NG tube is uncomfortable and let's talk about that. And then the other is that actually the guidelines on NG tubes and bowel obstructions have changed. I don't want to give away how long I've been doing this, but let's just say that it used to be that patients with small bowel obstructions all got their NG tubes in the ed. And you guys probably know that that's not really happening anymore. And the especially for Malignant small bowel obstruction. The recommendations are actually, we start with medical management, and if medical, pharmaceutical management does not relieve their symptoms, then you're thinking about an NG tube. And in someone who's really uncomfortable, and I can't get them comfortable within the, you know, first 30 to 60 minutes, sometimes I might talk to them about an NG and just get a couple liters out and make them feel better some. For some people, it is a huge relief, but I don't really want to leave that NG tube in if I can help it.
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C
Okay.
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D
Yeah.
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C
Okay.
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D
And if they need an NG tube, then we. We've got to be talking about something different, which I suspect we're going to get to.
- [21:24]
C
We are.
- [21:25]
B
All right. What? A segue.
- [21:27]
D
Segue.
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B
So obviously, the NG tube is, like, usually opening up a hornet's nest of other questions of procedures which, like, your whole sussing out the situation's, like, very proactive. But the other things on the table are surgical consultations for some kind of stenting, venting G tubes. So when or if is there a best. Best time for these? And who do you kind of call for these? So let's start with the like, when slash. If this is ever appropriate. Let's start there.
- [22:02]
D
Let's start there. So a side note is that the interventional GI procedures. So let's say stenting procedures, totally appropriate, say, for a gastric outlet obstruction, maybe palliative for a colonic obstruction. But in this very specific definition of malignant small bowel obstruction from peritoneal carcinomatosis, stenting is. There's no role there. So then you can say, well, how about surgery? I mean, if the patient sort of fails to, as we say, open up in some period of time, could we take them to the or? And the answer is almost always no. And the reason is multifold. First of all, these patients usually have multiple obstructions. Like, maybe there's one transition point that you're seeing on the scan, but usually they have multiple obstructions, and that's just not surgically treatable. Furthermore, all the things that make someone not a great surgical candidate tend to apply here also, like malnutrition, poor performance status, ascites.
- [23:12]
B
Mm.
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D
Trying to think of all the other things, but it's just. It's not an ideal situation, especially when you can't fix multiple obstructions. So we talked about stenting. We talked about surgery. There are lots of cases where I do involve my surgical colleagues, but very few cases. In fact, in the last five years, I don't think I've seen anyone go to the or. So sometimes you need to involve them. And sometimes the patient wants to know, like, please, can I have surgery? You know, so we need an answer to that. And then the last question is the most important, which is the venting G tube. So just for those of you who don't do this every day, a venting G tube is just like a feeding G tube, except that it actually vents the secretions, the gastric secretions, and anything that you eat or drink just goes right through into a tube. It's like a Foley bag. So in someone with certainly complete bowel obstruction that can't be otherwise treated, we recommend, you know, at Kashlak Northeast, we recommend early G tube placement, venting G. And actually, I think most of the literature sort of leans in that direction is early placement. Even for patients who, like, they get a little bit better, maybe then they get a little bit worse, and then they get better, and maybe the octreotide and the Haldol and everything else is working. We know that their readmission rate from obstruction is about 50%. Their 30 day readmission rate for any cause is about 75%. And just to add some more data in here to overwhelm with data is once you have this diagnosis, most people spend a third of their remaining time in the hospital. So if you can get them a venting gift, even if they're feeling good, they can clamp their venting G, they can put it under their clothing, and then if they have an acute event, they can unclamp it and they don't have to come back to the ED, sit in the ED for 24 hours, you know, waiting for a bed upstairs, et cetera, et cetera. So it's sort of a little bit of a release valve to keep them out of the ED and keep, you know, keep them out of the hospital.
- [25:27]
C
Real quick, when you say early placement, it is that that's referring to time of the malignant bowel obstruction, like kind of diagnosis of that, not before that. Because not everyone with X.
- [25:40]
D
True.
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C
Right.
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D
Okay, that's a good question. Early placement, meaning on the first presentation as opposed to waiting for the second
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B
or third presentation before we close out this section. In the catacombs of my mind, caring for a patient with a malignant obstruction from a while ago, and this might just be old thinking, is there any use for steroids?
- [26:03]
D
I love that you asked that. So the data for steroids is not great, but like many things in oncology, we do whatever it takes to make people feel better. And so Sometimes we'll do a trial of steroids, and it's usually dexamethasone, like 2-4mg IV. And we give it for a few days, and if they feel better, great. You know, there was probably an inflammatory component of the obstruction, so. Yes. And then, you know, it's. We can consider it as an. As an option in that. Metoclopramide, haloperidol, olanzapine combination. Octreotide combination.
- [26:44]
B
Okay. No, like I said, this was just coming from the catacombs of my career and just.
- [26:48]
D
I kind of like that word. The catacombs of your career.
- [26:53]
B
Yeah. So, yeah, that was just a question I wanted to ask about.
- [26:56]
C
Yeah. I think the same catacombs situation in the procedure, one that we don't. We didn't talk about beforehand, is paracentesis, because I think there's also the conversation that often comes up about, you know, seating and all that, but, like, they already have spread. So if the paracentesis makes them feel better or you do it, and if.
- [27:19]
D
Okay, definitely we do a paracentesis a day on our service just to make people feel better. The other thing you should know, though, is sometimes it's a little bit tricky to. To put in a venting g in a patient who has tense ascites because they can't oppose the, you know, the stomach to the. The wall of the abdomen if there's tense ascites. And so sometimes we do a peritoneal drain, like a Denver drain, at the same time as the venting g. Okay,
- [27:50]
C
so we'll kind of. Then you were referencing this actually, a minute ago, but if we could talk a little bit about prognosis. You mentioned, you know, the. Once patient is diagnosed with the malignant smile ball or malignant bowel obstruction, you know, a third of their time is spent in the hospital. We've kind of talked a little bit about sussing out some of, you know, where they are on their cancer journey, but I think having also an idea of some of the prognostic information would be helpful too.
- [28:20]
D
Yeah. So in this particular case of peritoneal carcinomatosis with small bowel obstruction, the median survival, I would make you guess, but it's so dismal. It's like one to two months. So it's really, really grim. And that's going to color all our decision making. And then the other data about readmissions and time spent in the hospital and time not spent at home, I think is really important to talk to our patients about.
- [28:49]
C
Yeah. And Then I think the other one that comes up kind of in the same conversation is then conversations around nutrition, which just always brings a pit to my stomach.
- [29:01]
D
It certainly does.
- [29:03]
C
Really bad pun there. But I'm just wondering if you could enlighten us about what to counsel about nutrition. What are best recommendations for nutrition?
- [29:11]
D
I don't know about you, but this is one of the hardest discussions to have with patients and their families and just to sort of get all philosophical for a second. Like, think about it. You know, food is love. Food is how we care for people. My son's in college. I send him home baked cookies. Like, I mean, what else can I do for him while he's in college? Right. So I send food. I mean, it's everything. And when families feel like there's nothing more that we're doing, you know, with chemotherapy or surgery or radiation, we're left talking about food. So it's a tough conversation. The way that I've heard oncologists discuss this is the oncologists generally say that as your body is shutting down, you are not processing nutrients the way you would normally, that these. That the nutrients that we would give you through TPN or other means are not being used. That's a little bit too kind of technical for me, I think. I tend to say that as your body is shutting down, you are not feeling thirst or hunger. And I try to steer the conversation away from the focus on nutrition to the focus on other ways that we can care, because really, nutrition is all about caring. And so if we can talk about other ways that we can show love and caring, that is sometimes helpful.
- [30:46]
C
That's an interesting one. So you would say, like, spending time together, those things, and lean into that.
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D
Yeah. And I know we'll probably be talking a little bit about end of life care here, but that really is all part of the discussion about what matters most. And that's what palliative care doctors always say is, you know, we gotta talk about what matters most. And it's usually not having IV nutrition being, you know, run for 14 hours at night.
- [31:18]
C
And so it sounds like definitely not recommending tpn. And like, we've also talked about these, patients tend to go from okay days to not so good days, and it can fluctuate a fair amount. So still allowing for, like, comfort feed for whatever they want to take in. And I guess if they have the venting G, they would have a way out of it.
- [31:41]
D
Yeah.
- [31:42]
C
And that's kind of best practice, not doing anything extra from that.
- [31:47]
D
Yes. And what the NCCN actually says, it sounds kind of cold and harsh, the words that are used. But essentially, if the prognosis is such that the cancer is more likely to be the fatal event than starvation, then clearly feeding would not be recommended. Now, there are exceptions, and I think it's worth saying, like, we have one particular patient that we at Cash Lock Northeast know and love who has a neuroendocrine slow, slow growing with a chronic bowel obstruction and a venting G. And he's on TPN because that's totally appropriate based on his prognosis. So there are exceptions there, I think. Also, though, just in speaking to med students and, you know, other team members, it is important to know that the literature does not show a benefit of TPN in terms of quality or quantity of life. Just to kind of go in knowing
- [32:47]
B
that, yeah, it's helpful to have data when you're saying something that feels counter to the way we've been wired our entire lives.
- [32:55]
D
Exactly.
- [32:56]
B
So it's good to have data. I think we'll kind of move along. So Mr. Locke has gone through this initial SBO, and he improves modestly with an NG, compression fluids, antiemetics, medical management. He goes home. Four weeks later, he returns with new swelling and pain in his left leg. He doesn't have any chest pain, no hemoptysis. He's pretty stable. Actually, when he comes in, the only thing that's really notable on exam is that he does have this unilateral left lower extremity edema to the mid thigh and mid calf tenderness. His no shocker, his lower extremity. Ultrasound shows an acute proximal DVT in his femoral vein. Hemoglobin's 9.8, platelets are stable and creatinine stable. So in these patients with colorectal cancer, it's pretty advanced. How do you choose between the DOAC and low molecular weight heparin? And does this fact, the fact that he's got a GI moleculency, affect that choice at all?
- [33:55]
D
Yep, that's the exact right question to ask. So either drug is totally appropriate here. You can use a DOAC or low molecular weight heparin. The NCCN guidelines say that in patients with gastric malignancies, so the highest risk bleeding patients or gastro or gastroesophageal lesions, you're gonna favor a low molecular weight heparin. But for this patient with colorectal cancer, he may have a slightly increased risk of bleeding if he has mucosal lesions. But he actually DOAC or low molecular weight heparin. Dealer's choice.
- [34:28]
B
And how long does he need to be anticoagulated? We're asking all the fun ones today.
- [34:32]
D
This is a good one. This is a good one. Cause a year ago the answer would have been different. So I love that we have new data. So the basic principle of anticoagulation in cancer patients is that you need to anticoagulate for as long as the patient has active cancer or is on active cancer therapy. So we in patients like this, we say indefinitely. Now that has changed slightly because there was that EPI cap trial. I have no idea what that stands for. So if you know, please tell me which showed that you could actually after six months of full therapeutic dosing, if the patient has ongoing active cancer and needs indefinite therapy, you can actually decrease the dose specifically of apixaban from 5 bid to 2 and a half bid. The efficacy is the same, but the bleeding risk is lower. So in this particular patient, if we're going to do a doac, we, we could go for six months and then decrease the dose. I'm not sure in this prognostic case that that is relevant.
- [35:42]
C
And I know we're talking really about colorectal cancer here, but you mentioned how colorectal cancer tends to have the higher bleeding profiles in terms of like the other cancers that we often see, those have just lower bleeding profiles. Where the doac, like when you're weighing DOAC versus low molecular weight heparin, it's favors the doac. Is that.
- [36:05]
D
Yeah. So actually it's gastric cancer that we really want to go with low molecular weight heparin. But any cancer with mucosal lesions is going to bump your bleeding risk. But the NCCN doesn't specifically say for colorectal that you have to use Lovenox. So really most of the time it's. It's DOAC is your go to. I mean, of course all the drug, drug interactions and all the cancer drugs that we use, we have to make sure that there are no drug drug interactions. But it is usually a doic. And I got to tell you, from a personal standpoint, I just had major orthopedic surgery. We talked about that. And you know, it goes along with major orthopedic surgery. Low banana. I am not a fan, so I empathize just a tiny little bit.
- [36:47]
C
That's good. That's good. So I think that's also a good segue unintentionally. So what about the cases where patient is found with like an incidental pe. They were scanned like they got their chest scan, find this like pe, but otherwise we're like, not symptomatic. What do you do with that information?
- [37:05]
D
Happens all the time. This is kind of the one area in which cancer guidelines are actually easier than general medicine. In general medicine, you might, if you found an incidental subsegmental PE that was asymptomatic, you might choose to watch that. We treat every. Every clot in cancer is an important clot. So we would treat. Absolutely.
- [37:31]
C
And what about how does brain metastases and risk of bleeding affect your decision making?
- [37:38]
D
This used to strike fear in my heart, the combination of brain mets and anticoagulation. Interestingly, I'm actually a little calmer with this combination now. And I think the important, you know, take home points for general medicine hospitalists who will likely encounter this is in most cases, you are going to anticoagulate. In someone who has an acute clot, you are going to anticoagulate. There are a few cases where you're going to have a multidisciplinary discussion, you're going to agonize about it, but you're probably still going to anticoagulate. And the cases that require a little agonizing are certain tumors that have really high risk of bleeding. So like renal cell melanoma, thyroid, and then something I've never seen and I probably will never see in my career, choriocarcinoma, very high risk of bleeding, I'm told. So the cancer itself, if someone has melanoma, I'm going to certainly have a multidisciplinary discussion before I start anticoagulation. And then the other thing is if they are untreated mets, so new metastasis is much more concerning for bleeding than a treated met. So if someone comes in and they've got small cell cancer, lung cancer metastatic to the brain, and it's been treated with gamma knife, I do not think twice. I anticoagulate that, you know, but untreated mets, it's. It's worth a conversation, although we will almost all. I mean, it's hard to imagine we wouldn't treat.
- [39:09]
C
Okay, so then let's talk a little bit too then about what medications patients may be on for their cancer treatment that is also going to impact their anticoagulation.
- [39:20]
D
Yeah. So the only one that really comes to mind are the VEGF inhibitors. That's bevacizumab. And the interesting thing about these drugs is they cause clotting and bleeding. So it's Entirely possible someone would present with an acute pe. At that point we would absolutely have to anticoagulate, but we'd probably reevaluate the VEGF inhibitor at that point. It would probably be discontinued.
- [39:46]
C
And then going back to the clots, for a second, we talked about like the incidental pe, but then there's also the incidental like of everything else. So like splanchnic, I feel like the one I always see is like a hepatic vein thrombosis managed, like you had said before, like all clots are going to be the same. All of that is also in that category of treat or those are different?
- [40:11]
D
Mainly. Mainly. So all clots are important? Yes, absolutely. We see lots of incidental splanchnic thrombosis, like mesenteric thrombosis. The rule is we treat all of them just like if it were a dvt. The only exception might be if someone had a chronic splanchnic thrombosis with full collateralization. The bleeding risk would then exceed the risk of. Of anticoagulant. Of not anticoagulating. I don't know how to say that. So in that case, you wouldn't anticoagulate. But realistically, these patients are scanned so often that finding a chronic splanchnic vein thrombosis with full collateralization. It's not gonna happen.
- [41:01]
C
How do you determine the full collateral collateralization? On the scan itself?
- [41:06]
D
On the scan.
- [41:06]
C
Okay.
- [41:07]
A
Yeah.
- [41:07]
D
And I think that's when then when you're concerned about this cavernous transformation and then the risk of bleeding associated with the cavernous transformation.
- [41:18]
A
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- [42:41]
B
Great. I'm just here to punish Mr. Block. Apparently. No, I'm just going to keep us moving. Poor guy. Two months later, he's admitted again with recurrent n vomiting and worsening abdominal pain. He's profoundly fatigued, spending most of the day in bed, lost significant weight. He reports minimal oral intake for the past week. He's mildly tachycardic, otherwise fairly stable. But he looks more chronically ill and more frail than prior admissions, and his abdomen is still distended and mildly tender. His repeat CT shows worsening peritoneal carcinomatosis, increased ascites, multifocal allow obstruction. Oncology evaluates them and feels that further cancer directed therapy is unlikely to provide meaningful benefits. So at this point, things have clearly changed and probably not in the direction we had hoped. How do you approach a patient with recurrent small bowel obstruction, progressive disease, declining performance status, and do you use things like the palliative performance score for prognostication or how do you.
- [43:46]
D
I don't use the palliative performance score. I'm not sure if my palliative care colleagues use it. It's interesting. It's actually not that different from just the standard ECOG score that most people are familiar with. And the EcoCHG is pretty easy to do in your head, you know, and just one of the things that always confused me when I started on oncology is that an ecochg of zero means you're fully functional. Zero. Like I kind of. It's a little counterintuitive, don't you think? But an ECOG of 5, then, is that you're deceased. So really you're looking at an. An ECOG of 2 or greater suggests maybe poor tolerance of chemotherapy. In any case, I. The ecog, you can do it in your head. When patients are ECOG of 3 and 4, that's when they're spending most of their time in bed, which is kind of what we're talking about here. And I. It looks like we're talking about progression to hospice care.
- [44:45]
B
Yeah, I mean, you know, I feel like I have a pretty good sense of when to call palliative care. This feels like probably the appropriate time
- [44:53]
D
or two months ago.
- [44:55]
B
And I mean early. Often. Working with Meredith for this many years has definitely increased. My palliative, like, my time to palliative consultation has decreased significantly because I hope so. Truebit's definitely really good at identifying those situations. Probably that's really helped my spidey sense just being in her orbit. So I guess the question that I think is important, especially when you're working with learners, working with people earlier in their career, is what can palliative care add here beyond what you are already doing, because you already emphasize the patient and making them feel better. So what is it that palliative care is adding?
- [45:34]
D
Oh, so much. Where to begin? Okay, the literature is pretty clear on everything that palliative care could do. And I can talk about the literature, but let me just talk from a personal standpoint. There is a lot that is involved in caring for these patients. I mean, it takes a village, right? So we're managing this complex medical condition. We've got all the social and emotional overlay. We're working with consultants. We're working with social work and case management. We're having family meetings. There's a lot to do. I kind of like to have a friend to do it with. It just is helpful. But more importantly, I think palliative care certainly has shown its value in the literature with this expert symptom management. For example, I don't know how to manage a ketamine drip, even a fentanyl pca. That, that's. That's above my pay grade. I mean, that's all palliative care. Expert symptom management of even, you know, nausea and vomiting. Sometimes I've. I've gone to line one five and I'm still struggling. It's really helpful to have palliative care for that expert symptom management on my service at Kashlak Northeast. We hospitalists actually do do all the goals of care conversations, but we usually do it with palliative care right at our side. Palliative care can really help answer questions that I may not have the answers to. It's nice to.
- [47:00]
B
It is. It is not infrequent that I say that I call palliative care to palliate me.
- [47:05]
D
Yes. Oh, yes. There's more to say on that front, too. That's a whole conversation.
- [47:11]
B
We're going to leave that for another episode.
- [47:13]
D
Okay.
- [47:15]
C
You referenced this a little bit when we were talking about nutrition, but I'm curious kind of what other language you use as you're really transitioning that conversation from really. To focus on symptom based care transition to hospice.
- [47:29]
D
I am not a palliative care doctor. I am not fully trained in this. But I have picked up a few tips mainly from doing it wrong, which is one way to learn. And so I think the most important thing is you have to acknowledge that this is a change. Like, they were in their oncologist's office a week ago. They were talking about treatment. We just started anticoagulation on this patient. Like, we're sort of. This is a big change that we're now talking about end of life care. I've seen patients really get pretty significant whiplash from like, wait, what? Who are you? And you're telling me what. So the sort of concept of, I wish I had better news, but your cancer is progressing. It's no longer responding to the treatments that we have. This. This hospitalization is different from your first bowel obstruction and this is why you're not feeling as well. And then talk about this change and what this change means to the patient and sort of what their thoughts are. I think that that's the. The first thing is to acknowledge this is a dramatic change. The other thing I have learned to do is. And you guys can correct me if this is. I'm not supposed to do this, but sometimes it seems to help if you normalize it and say something like, you know, in my experience, patients in a similar situation make these kinds of decisions and then it normalizes the conversation and takes it sometimes away from that horrible personal decision to talk about what other people choose. That sometimes helps. I also have a long list of things you shouldn't do. If you want to hear that, I
- [49:11]
C
think we should do that. I agree. I have also learned a lot from when you say something and then you're like, well, not saying that one again.
- [49:19]
D
Nope.
- [49:21]
C
And I think the more that we share those out loud, it helps anyone at any stage of their career to not also step in it that way.
- [49:28]
D
Yeah, exactly. That's what it feels like as soon as the words have left my mouth. Exactly. I am reaching out to take them back because they just didn't come out the way I wanted to. And now there's no turning back. No turning back. Yeah. So I'll tell you the one that residents often make. And we all did it. Walk in the room and start talking about code status. That. That's kind of a non starter. That's. We want to know how the Patient is feeling what their aspirations are. How do they want to spend their remaining time? But jumping right into code status, there are very few people who'd be like, yeah, you know what? You don't have to treat me anymore. I'm good. Like, most people are like, yes, do everything if you start there. But if you start with, you know, what are your priorities and learn a little bit about them, then the code status just follows naturally.
- [50:23]
C
Yeah, that one's always painful.
- [50:25]
D
Yes, it is.
- [50:26]
C
Yeah. There's no. I agree. Anytime you bring up code status, it's like, yes, I want everything. Why would you ask.
- [50:34]
D
Why would you even ask that?
- [50:36]
C
Yes, exactly.
- [50:38]
D
Oh, boy. I think that. I mean, there's a long list of things that I've done wrong, but I think in general, it is best to have these conversations when you're not talking about a specific medical decision that needs to be made, because then everyone perseverates on that medical decision, whether it's surgery or TPN or whatever it is, and you kind of lose sight of the big picture. So better to do it out of that context.
- [51:05]
B
Yeah. The framework, hilariously, this came from one of my ICU attendings, actually, that I have used so often, and it really resonates. I think I've noticed it more in slightly older patients that have things like that. But the frame that he would use is like, you know, there's a lot we can do to you, but what are we doing for you?
- [51:23]
D
Oh, I love that. Love that.
- [51:26]
B
You can see it click a lot of the time. Like, the. Especially the patients that, like, keep coming back to the hospital, and they, like, every time they're getting lab draws and they're getting procedures and, like, all those things, and, like, that's a frame, actually just came up on rounds a couple weeks ago when I was on service, and the t. Like, I don't think the residents had heard that frame before, and they're like, we're banking that one.
- [51:46]
D
Yeah, that's.
- [51:47]
B
And I have used that since the time I heard it when I was a resident.
- [51:51]
D
Yeah.
- [51:53]
C
So before we go into this, you know, this could be its own episode, too. I want to talk about two scenarios for this. This has come up for me recently in a few different situations, but one where, you know, what does it look like for Mr. Block going home on hospice? What does that look like for him visually? But also, what if you have shared all the information and he is still like, either, I'm gonna go get a second opinion, or I'm not on board for hospice? How do you kind of set that up for home? Because there may not be anything else you can offer, and what you are functionally doing is the same in both, but it feels different.
- [52:32]
D
Very different. Yes, it does feel different. Okay, so the first question was about a good hospice discharge. So make sure that the patient is enrolled in hospice before they physically leave the hospital. I think that is my first take home point. Then make sure that hospice is coming within 24 hours, because the worst thing that could happen is they get home and they don't. They need something or something happens and hospice is not there. We do not want this person to end up back in our emergency department that is not within their stated goals of care. So let's make sure everything's set up. Of course, then you want all their DME set up. Usually that. That includes a hospital bed. Most of our patients at this point really aren't. We're not talking about wheelchairs and shower chairs and other things. Usually it's just a hospital bed. But it's easy to overlook some other things too. Like, really easy to overlook. If they have a venting G tube, they need supplies for their venting G tube. Wouldn't that be awful if they got home and they didn't have those supplies? So making sure that the family is educated in all of that. I think the other thing. One more thing here, one more thing. Is that talking a lot to the family about what to expect and how to wave the white flag if things aren't going well, taking care of a family member on hospice is really, really hard. Like, if you're not a nurse or a doctor or a medical professional, it is overwhelming, hard. And I guess normalizing that so they don't feel like they're somewhat inadequate because it doesn't look the same way in real life as it does in the movies. And then who they're supposed to call when things go awry. Oh, I was. I was hoping I could get around.
- [54:21]
C
I know.
- [54:22]
D
I feel like. I feel like we're running out of time.
- [54:25]
C
All right.
- [54:27]
D
Okay. So this is one of the hardest circumstances. So this is the circumstance where you've patient has a very poor prognosis. Like this circumstance, they're clearly failing clinically, functionally, and yet they. Let's full steam ahead. ICU if I need it, you know, supplemental nutrition if I need it, everything I. Blood transfusions, I want to do it all. So you've done your very best. You've had all sorts of family meetings and goals of care conversations, and it's really clear this is what they want. I think the most important thing is you do have to respect their wishes. The concept of goals of care is. It's not my goals of care, it's the patient's goals of care and they have expressed them and we need to respect them. Unless there are some overlying ethical issues, we do need to respect them. I think we tend to badger people too much in these circumstances. I think we go in every day and have another goals of care conversation. And I can tell you that's not going to help. You're going to alienate the family. You're, you're, you're not building trust, you're doing the opposite. So take a deep breath, let a few days go by, see if the circumstance changes and see if we need to reevaluate. My one little pro tip here is to sometimes these circumstances arise for religious reasons. And sometimes if we bring in their religious leader from the community, the person with whom they actually have a relationship, sometimes that helps work through these end of life issues.
- [56:08]
C
That's a good pro tip. And when they are ready, otherwise, I guess ready for discharge, like, you know, you're not making it better. Do you try to just optimize the symptom directed therapies the best you can? Because that's really what we like at that point is your best care you can provide.
- [56:26]
D
Yeah, that's the best that we can do. And sometimes not just sometimes. A lot of times we, you know, we wait for the next admission and maybe the next admission is when they're like, okay, now I'm not, I'm done, I'm done now.
- [56:43]
C
I think I just wanted to end saying this, but I think knowing that you feel uncomfortable in that provides me more comfort that you're not like none of us are alone when that discomfort happens in these cases. So I think that's important.
- [56:57]
D
It's really hard.
- [56:59]
C
So I think we'll go ahead and see, you know, what are your take home points from this whole talk?
- [57:04]
D
Oh my goodness, there's so much pick, pick one, two, pick two. I get two.
- [57:10]
B
You pick two or three. We'll do three.
- [57:15]
D
I think the most important take home point is that malignant bowel obstruction in this particular scenario with peritoneal metastases, it's a turning point. It's a terminal event. It really is time to reevaluate goals of care. And then I think my next point since I get two, is that venting gastrostomy tubes are underutilized or utilized too late.
- [57:39]
C
I think those are two good ones.
- [57:41]
B
And then we would just like to plug for anyone that goes to SHM at any point since this will air after, please go to a Jensen Morris talk. The reason that we picked Dr. Morris was that Meredith saw her talk at the 2025 SHM and we just were really excited to hear her speak and really wanted to bring her on air. So if you ever have the opportunity,
- [57:59]
C
wanted to be friends, so wanted to be friends.
- [58:01]
B
And really if you have the opportunity, please make sure you seek her out. Really good stuff.
- [58:05]
C
Yeah. All right, this has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [58:15]
B
Yummy.
- [58:17]
C
Still hungry for more?
- [58:18]
B
Yep.
- [58:19]
C
Join our Patreon and get all episodes ad free twice monthly bonus episodes@patreon.com curbsiders. You can find show notes@the curbsiders.com and sign up for our mailing list to get our weekly show show notes in your inbox including our Curbsiders Digest, recapping the latest practice, changing articles, guidelines and news and internal medicine.
- [58:36]
B
And here at the Curbsiders we're committed to high value practice, changing knowledge and to that we need your feedback so please email us@ or askcurbsidersmail.com it also helps a lot when you subscribe, rate and review the show on YouTube, Spotify or Apple Podcasts. A reminder that this and most episodes are available for CME credit for all healthcare professionals through VCU Health at Curbsiders. VCU Health A special thanks to our writer and producer Dr. R.J. blackburn for this episode and to our whole Curbsiders team. Our technical production is done by the team at Podpaste. Elizabeth Proto does our social media. Jen Watto runs our Patreon. Chris the two Manchu moderates our Discord. Stuart Brigham composed the theme music and with all that, until next time, I am Moni Amin.
- [59:17]
C
And I am Meredith Trubitt. Thank you and good afternoon.
- [59:41]
D
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A
With Verbocare. Help is always ready before, during and after your stay. We've planned for the plot twists so support is always available because a great
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D
trip starts with Peace of Mind.