Diabetes patient chooses to forego meds in hospice care
DEAR DR. ROACH: My dad has been on hospice care for several months now. He had an untreated wound infection that was not responding to meds, so he went on hospice. Also, his wife died, and he lost the will to live after that.
His sugars are well into the 400s. He is on pain meds and nothing else. His doctor says he should not have lasted this long, medically speaking. He gave me no other explanation except a shrug. His spirits are OK, but I fear something else will get him in the end, like bed sores, pneumonia, a fall or COVID. Is it normal for a diabetes patient who no longer takes their medication to linger like this? He is not suffering per se, but quality of life is not good either. — H.D.
ANSWER: The goal of hospice care is to provide comfort to a person in the last phase of their life. If your father was thought by his physician to have a condition that was likely to end his life (normally, an expectation of end of life coming within six months is a necessary condition for hospice care), and he made up his mind to choose this option (and understood the consequences of that action), then hospice is a reasonable choice.
Elevated blood sugars in people in hospice care are common. They are often not treated, as they usually do not cause symptoms. Elevated blood sugars over months (or years) predispose people with diabetes to complications, including infection, heart disease and stroke, but in a person in hospice care, these considerations are less important than the overall goal of reducing suffering. Medications are given orally whenever possible and, again, only to relieve symptoms.
Something will indeed “get him in the end,” as it will for all of us. People in hospice care have accepted that. It can be hard for family members, especially when there is not an immediately terminal disease like cancer associated with the hospice care.
DEAR DR. ROACH: My wife was just diagnosed with Paget’s disease of the breast. Is it true that surgery is the only option for treatment? We’ve never heard of this condition. The biopsy shows no cancer beyond the nipple area. — B.W.
ANSWER: Paget’s disease of the breast is an uncommon type of breast cancer almost only ever found in women (the more common type of breast cancer is found in men about 1% of the time, but PDB is extremely rare in men). The disease looks like a scaly or raw lesion on the nipple, which usually spreads to the areola around the nipple. Most women have itchiness, pain or burning, which often starts before — often months before — any skin changes. A careful exam and mammogram should be performed by an expert in women with symptoms of PDB, or with something abnormal she can see or feel on the nipple. The prognosis is much better in women who do not have a mass that can be felt on exam.
Surgery is almost always part of the treatment plan. Depending on the stage of the disease, some women will need a mastectomy, but in some cases, women can be treated with breast-conserving surgery (also called “lumpectomy”) followed by radiation treatment. There is no standard recommendation on medications, such as tamoxifen, in the treatment of PDB.