Abstract
Thirty-three degrees centigrade measured, 36°C perceived … Sicily wakes up on a Saturday, as usual, to take people to the sea. Dr. Massimo, a home palliative care physician, is not among them. Today he is on call for advanced cancer patients followed by a home care program. Massimo's wife is confident. “Come on, hopefully no one will call”… Driiin… “Yes madame…”. He nervously looks at his optimistic wife who is already wearing a swimsuit. She is still adamantly confident: “okay, someone calls… but may be you can answer from home, sitting under the air conditioner!” Drinnn… “Yes madame…”
And so on for the next 10 calls. At each call, he looks at his wife. His wife's smile is now more discreet and less encouraging. Until a phone call arrives with which the local palliative care service warns of the need of a protected patient to be discharged to home, which will presumably take place in the afternoon. Now his wife has surrendered to the evidence and is sorry for Massimo. She looks at him sadly, while sipping her drink in the hammock, in the shade of the olive trees. “My love, be confident… you'll be back soon.”
Dr. Massimo goes from a town on the outskirts of east Palermo where he lives, to Mondello, a sea village on the west side. It is 2.30 PM in an overbearing preview of the Sicilian summer. He faces the traffic with a lion's heart, as someone who has been discharged from the hospital is counting on him. When he gets to Mondello, loaded with folders and good will, he discovers with terror that he has left the phonendoscope, oximeter, and sphygmomanometer at home. The patient's wife assists him, reassuring: “keep calm doctor, there is no hurry!!!.”
Strengthened by the fact that he does not see an emergency, he drives back home for 36 km. While driving he gets two more calls. They seem to be emergencies. He warns his wife: “I know I'll be late.” She does not give herself peace, and encourages him: “give love, I'm going to finish the aperitif with friends, and I'll order a pizza for dinner!”.
He visits the first patient. Rolando is an 86-year-old man, with an advanced lung cancer, with agitated delirium, preagonic state, and severe dyspnea. After extensive discussion with family members on the likely imminent death, he administers morphine and waits for the effect by noting the dosage given in the form. Symptom control appears satisfactory. He trains family members to administer additional doses and he leaves. The second patient is Maria, an 85-year-old woman, affected by metastatic colon cancer and a concomitant cerebrovascular disease. A colleague of the team had already contacted him in the morning to report a state of new onset. The patient now is agitated and confused.
He collects the anamnesis of the last few days and a recent increase in transdermal fentanyl dose emerges. Dexamethasone 4 mg had been administered in the morning. Dr. Massimo hypothesizes a drug-induced hyperkinetic delirium and prescribes a wash out with intravenous hydration, removing the fentanyl patch, and promoting night rest with levosulpiride. The effects will not be seen soon, so Dr. Massimo explains to family members the rationale, giving instructions to update him by phone. He leaves at 8:30 PM and goes back to Mondello for the protected discharge.
Sergio is a 65-year-old man, extremely active despite his illness. He has been fighting against a gastrointestinal stromal tumor for some time and until now the disease had not prevented him from living his life. Owing to an occlusion of the urinary tract secondary to localization of the disease, he underwent an urostomy: for the first time the signs of the disease are visible to him and to others. Dr. Massimo explains how to hide the urine collection bag under clothing, and also how, if necessary, to go to the sea. The conversation is pleasant, time passes, and at the end they say goodbye.
Dr. Massimo makes his way home, perhaps the pizza his wife ordered with so much tenderness is still warm, but the phone rings again for a new emergency. On the way back, while he is still thinking about that, a second call comes. He must visit other two patients, the last of the day. Filippo is a 75-year-old man suffering from multiple locations of a poorly differentiated cancer. Over the past hours, he has reported restlessness and hypogastric pain associated with bladder tenesmus. Upon Dr. Massimo's arrival, Filippo appears confused, at times he complains.
The bladder catheter is patent, previously checked by the nurse on call. Dr. Massimo prescribes tramadol, and eventually chlorpromazine, as a sedative. It's 10.30 PM. The other patient is Amedeo, a 55-year-old male. He is affected by multiple localizations of squamous carcinoma starting from the right leg, but what appears evident is his advanced liver disease. Family members have called because he has been suffering and restless for several hours. He is waiting for his brother who is driving back to Palermo from Northern Italy. He was a former drug addict and refuses those drugs that evoke the feelings he experienced in the past.
He would never accept a morphine prescription, which is what Dr. Massimo would order. In the meantime, it is 11.00 PM. After a long conversation the patient is exhausted and finally accepts an oral sedative, promazine, finally finding some relief. It is now well past midnight when Dr. Massimo arrives home, where his wife is waiting for him, asleep on the sofa.
On Sunday Dr. Massimo speaks with them again on the phone: Rolando died in the morning, calm (at least so the family members say), requiring only one further administration of morphine. Unfortunately, Amedeo also died before being able to see his brother. The sleep of Saturday night accompanied him until his death on Sunday. After an apparently quiet night, Filippo now appears agitated again; he has already used tramadol with little benefit, and chlorpromazine is recommended by phone. He dies in the afternoon, while sleeping.
Maria, in contrast, is better. She is calmer and has had a good rest; she is now appearing to be more compliant (in the following days she will also resume assisted feeding). The day ends with several other manageable remote calls, with all due respect to his wife who endured the telling of a story of a quiet on-call weekend that has just passed…