Abstract
Dear Editor:
A 33-year-old woman with a history of metastatic breast cancer was transferred to the intensive care unit (ICU) for further management of her acute respiratory failure. She was diagnosed with Stage III Estrogen receptor+, Progesterone receptor+, HER2 neu+ breast cancer five years previously and had developed bone and pulmonary metastases despite multiple different therapies. The patient was vacationing with her family when she developed acute respiratory failure requiring mechanical ventilation secondary to influenza and staphylococcal pneumonia. Although she received appropriate antimicrobial therapy, she was unable to be extubated. Despite being on high doses of pain medication, the patient remained awake and alert throughout her ICU stay and was able to communicate via writing. One thing that she continually expressed was her desire to go home and spend more meaningful time with her family, including her three-year-old son. After a large multidisciplinary discussion involving the patient's primary oncologist, the ICU team, and the palliative medicine team, we offered the patient a palliative tracheostomy with continued mechanical ventilation as a bridge to inpatient hospice and then home hospice, if possible. The patient underwent tracheostomy and was subsequently discharged to inpatient hospice where she spent a month before her death. That stay was characterized by celebration of significant events and holidays with close friends and family, including daily visits with her three-year-old son who enjoyed coloring at her bedside and riding his bike up and down the hospice hallway.
Discussion
This case illustrates a unique use of palliative tracheostomy for a patient at the end of life. The patient benefitted for numerous reasons. First, tracheostomy improved her ability to communicate; instead of just writing, she was able to mouth words and whisper. Second, it improved how she looked and her ability to use facial expression as part of nonverbal cues. This was particularly important to the patient as she wanted to appear like herself, especially to her three-year-old son. Last, tracheostomy improved the pain associated with the endotracheal tube and so her pain medication requirements were decreased. She was even able to eat some and frequently requested “slushies” as the ice also served to soothe the throat pain she experienced due to her prolonged intubation.
However, there are potential burdens for a treatment like this. Tracheostomy has been associated with a wide range of emotions and feelings, including confusion, shock, and frustration, surrounding an inability to communicate. 1 Additionally, when compared with noninvasive ventilation, tracheal ventilation is associated with increased caregiver burden, including increased time spent providing care, increased nighttime awakenings, increased health problems, and higher rates of unemployment. 2 Last, there are costs associated with this invasive procedure as well as potential medical complications. 3
If presented with a similar case again, we would pursue the same strategy. However, given the complexity of the issues surrounding palliative tracheostomy, it is important that cases be discussed by a multidisciplinary group, including palliative care team members, before offering this intervention to a patient. Palliative care team involvement in the decision whether to pursue tracheostomy at the end of life has been associated with lower rates of inpatient mortality and higher rates of home discharge. 4 Furthermore, a collaborative relationship with a hospice program willing to provide this care is essential.
In summary, we present the unique case of a patient with metastatic cancer who achieved increased time and quality of life with friends and family while in inpatient hospice due to the placement of a palliative tracheostomy. We believe that in a carefully selected patient population, palliative tracheostomy may be considered as a means to improve individuals' quality of life at the end of life.
Footnotes
Acknowledgment
We thank the family members of this patient for their insight into the benefits of palliative tracheostomy and their contributions to this article.