Prognosis with pancreatic cancer is pretty much always awful, even with surgery and chemo. In fact most of the time, those treatments ARE palliative and that's about it. It reduces pain. It can reduce pressure on various ducts and that can be helpful. Almost never curative or gives you more than 1-3 years.
I'm fully aware of how awful pancreatic cancer is. As Celexa said there is a huge range for "palliative care" and there is a big difference between someone having corrective procedures done (duct obstructions) who has years to live vs someone with a couple months or less who is basically on comfort measures only (which may include minor procedures like paracentesis). Imo those are very different patient populations who should be approached quite differently.
i agree in hospice where its clear they're at the end, but palliatve care, they may have a 5+ year prognosis or more and I hate to make someone stop breathing when they could have lived at least another five years. Xanax is never worth five years of life. I just generally hate benzos+opioids though.
Pancreatic Cancer Prognosis
Long-term prognosis for pancreatic cancer depends on the size and type of the tumor, lymph node involvement and degree of metastasis (spread) at the time of diagnosis.www.hopkinsmedicine.org
I meant to post this. For everyone that discussed pro/cons of medicine that had to do with QOL and other factors, that's great. But I wouldn't worry about dependency or hospice status in the OP's patient. Unless we're talking about the 1 put of 100 patients that will see cure, or the 1 out of 10 that will even survive 5 years.
It's hard to predict if this guy has 6-12 months or will have 12-36 months.
So you're going to be conservative with what another poster made the great case was the most effective treatment for anxiety that we have, and potentially make this guy's life experience worse, because he hasn't given up hope and been put on hospice? So you'll prescribe thinking he lives 3 years, but then he only gets 11 months? And those 11 months were less comfortable because you were worried about 2 years he never got to see? Sure you'll probably see that he's not going to make it past 11 months at some point....
I didn't even get into how patients will resist hospice just for psychological reasons, even if not being on hospice really changes much as far as management.
It's not that difficult to figure out for yourself from the notes this guy's prognosis.
At this point patients can see all their notes quite easily.
In terminal patients I've frequently seen plain talk about the worst prognoses buried in the notes or seemingly hinted at just by stage. Oncologists and surgeons sometimes forget other specialists frequently can't glean from the notes what is going on in plain talk. Stage 4 pancreatic cancer is pretty much its own code phrase.
Also I should have noted but didn't until I reviewed, is that it isn't unusual to go in with a plan for cure and during the surgery itself make the discovery this is a palliative only situation. Maybe the patient hasn't been fully differentiated. It would be reasonable to see where that goes before making big medication changes.
Why not send a note to the guy's oncologist or surgeon? Talk to them. I highly doubt they're going to tell you benzos are gonna make these guy's prognosis as far as cancer progression/chemo worse.
Also, isn't it reasonable to discuss with the patient the risks and benefits and goals of care? Why shouldn't he get to decide if anxiety treatment and risk of worse prognosis is worth it or time off his life? Don't we know from assisted suicide how much some patients are willing to trade extended life for comfort? (Not that this patient may be to this extreme, I'm saying goals of care are not always what you think, even in patients who are pursuing life extension through treatment). Don't we know from that the value that any degree of control over their illness has?
These considerations are fine, but you're not creating a lifelong drug addict here. Present everything here, but leave it up to the patient. They should have access to whatever treatment makes them comfortable, even if they aren't hospice or comfort care measures only. The OP asked about a palliative care situation in a 70 year old with pancreatic cancer.
I just can't even believe that we wouldn't take our cue from the patient in a case like this, because of a general distaste for benzos and opioids. Why are these drugs even allowed for medical use if not for some of the most deadly languishing agonizing cancers there are? And for someone dying like this it wouldn't just be "make a wish." And why you have to go full hospice or comfort care, agree to just die, before you would get the choice for maximum palliation of symptoms? He can't want a chance of an extension of life through chemo, but be willing to risk benzo and opoids combination kills him comfortably before then?
Are you guys just being devil's advocates?
Probably doesn't matter. I wonder why the psychiatrist was consulted. Maybe because this is already a psych patient There's someone out there who understands palliative care in a patient like this who will liberalize as needed.
There are sometimes good reasons to use benzos. There is never a good reason to use Xanax (except in Xanax withdrawal).
That's a very bold statement that many of us here and most psychiatrists I work with in real life would adamantly disagree with. By that line of logic why aren't we just using them first line for anyone with severe anxiety who have poor QoL because of that? Where do you draw the line? Even in palliative patients, as much as I've seen benzos used for end-of-life anxiety, they're also not nearly as effective as some people (both medical professionals and the general population) perceive them to be and Candidate2017's point about need for escalating doses to likely unsafe levels is a very valid one.
aacrjournals.org
If it were this straightforward it would be easy, but imo the bolded is ridiculous. If they say that high doses of LSD and Ketamine make the comfortable are you going to prescribe that? Even if it kills them far faster? I feel like you're making a lot of assumptions that we don't know and advocating for us to act more like drug dealers than doctors here. If they should get whatever they want, why are we even involved? (This isn't a personal attack, just genuine and semi-rhetorical questions).
It's not from a general distaste of benzos and opiates. It's because they're dangerous drugs that absolutely cause significant harm and kill people. Frankly, their medical use should be far more restricted than it is and as I mentioned above true palliative/comfort/hospice care is one of the only times I make an exception to recommend "long-term" regular benzo use in patients. I pretty much never start benzos for anxiety, and if you review the threads on here many of us follow that policy. You don't necessarily need to be "hospice status", but there needs to be a dramatic improvement in QoL with use of these meds to offset the risks, even without the concerns for developing dependence or an SUD.
I generally agree, but the study I linked above actually suggests that Xanax is a safer benzo for pancreatic cancer patients than some other benzos and actually improved prognosis. Obviously needs further research and I hope a benzo other than Xanax is found to be just as safe, but just something I thought you'd be interested in since we likely see some similar demographics. It has actually changed some of my recs for these patients irl.
Same, and I'd like to see data on other benzos in terms of safety in cancer patients for shorter-term palliative patients. Difference it's made for me is just that when a patient is already getting Xanax I'm less likely to try and switch to another longer-acting benzo (much less likely to recommend ativan) in a palliative setting. Not sure if palliative team continues those recs on d/c, but they're the ones managing meds, so I ultimately defer to them either way.
Fair. I should have said "there's never a good reason to START Xanax".
If they escalated to 1mg qid Xanax I doubt the xanax ever actually made the patient comfortable. That screams 'we just kept trying what didn't work the first time, just more of it'.
Not everyone who takes potentially abusable medications is an addict and I would say that most addicts get their drugs the old fashioned way from bartenders and dealers. We tend to see a slice of the addicts who are a bit different and tend to have cooccurring disorders. These are some of the most difficult patients and there are few good options for treatment. This leads to problems for us and the system and this leads to frustration that can bleed into other patients who are not really the problem.
