Burt Masden, a 61-year-old single retiree, calls his niece in a neighboring state at 10:00 P.M., stating he’s too weak to care for himself or his dog. She advises him to call 911, and says she and her husband will arrive the next morning to take care of his dog.

When the ambulance crew gets to Mr. Masden’s house, they find him alert, oriented, and extremely pale. He is able to walk to the ambulance using a cane. On arrival at the emergency department, his vital signs are temperature 97° F (36.1° C), blood pressure 101/54 mm Hg, heart rate 104 beats/minute, and respiratory rate 18 breaths/minute. He complains of increasing pain in his chest and left shoulder and hip, as well as generalized weakness. He reports he has lost weight and had a poor appetite for the last 2 months, and says he didn’t seek treatment sooner because he thought no one would be able to care for his dog.

History, physical, and diagnostic test findings

Mr. Masden’s previous medical history is negative except for a childhood appendectomy and a 40-year history of smoking two to three packs of cigarettes daily. He reports no allergies and takes no medications. He says he hasn’t seen a doctor since his discharge from the Army 40 years ago. His father died at age 74 of a lung tumor and his mother died at age 87 after a stroke.

Admission blood work reveals a hemoglobin of 5.6 mg/dL, hematocrit of 19.6%, and a serum potassium level of 2.7 mg/dL. The patient’s electrocardiogram is normal and his cardiac isoenzymes are negative.

Medical diagnoses

Mr. Masden’s admitting diagnosis is “anemia; rule out GI bleed.” He is admitted to the telemetry unit, where he receives I.V. fluids and potassium, plus two units of packed red blood cells.

He then undergoes a chest X-ray, which shows a large left upper lobe mass suspicious for cancer. Results of subsequent esophagogastroduodenoscopy and colonoscopy are normal. Based on these findings, the patient’s diagnosis is revised to “probable lung cancer; rule out metastasis.”

Computed tomography–guided lung biopsy confirms the diagnosis, and stage 4 non-small-cell lung cancer (a Pancoast tumor) is diagnosed. A metastatic workup reveals a large left adrenal mass and a lytic lesion of the left femur.

Despite receiving hydration, blood replacement, and adequate nutritional intake since admission, Mr. Masden grows increasingly weak. The neurologist finds he has absent deep tendon reflexes and severely decreased pain and temperature sensation in the extremities. Consequently, the patient gains an additional diagnosis: Lambert-Eaton myasthenic syndrome. A type of paraneoplastic syndrome commonly associated with cancer (most often small-cell lung cancer), Lambert-Eaton disrupts communication between nerves and muscles. (See Pancoast tumors and paraneoplastic syndromes by clicking on the pdf icon above.) The healthcare team concludes that the anemia Mr. Masden had on admission stemmed from Lambert-Eaton syndrome, not GI blood loss.
Mr. Masden’s medical diagnoses are end-stage lung cancer with adrenal and bone metastasis and paraneoplastic syndrome.

Course of illness

Mr. Masden has typical signs and symptoms of Lambert-Eaton syndrome, such as difficulty walking, muscle tone loss, and numbness and tingling of the arms and legs. These problems make it hard for him to write his will. His declining motor function restricts his ability to feed and shave himself; his weakness and poor lower-extremity tone and reflexes limit his ability to transfer from a bed to a chair. The lytic lesion on his left femur puts him at high risk for fracture.

Nursing diagnoses and related care

Nursing care for a patient with Lambert-Eaton syndrome depends on the nursing diagnoses. Mr. Masden’s nursing diagnoses include:

• self-care deficit
• pain
• denial
• anticipatory grieving.

Self-care deficit

Mr. Masden needs assistance with all activities of daily living. He requests and receives a tape recorder so he can record messages to help him get his affairs in order. A lawyer visits him in the hospital to prepare a will and a power of attorney.

Pain

Transdermal and oral medications, given in a regimen that combines around-the-clock with p.r.n. dosing, help control Mr. Masden’s pain. Transdermal nicotine minimizes his nicotine withdrawal symptoms (which can exacerbate pain and anxiety). He also uses nonpharmacologic pain-control measures, including distraction therapy provided by listening to music. As Lambert-Eaton syndrome progresses, his pain seems to decrease and he needs less p.r.n. medication.

Denial and anticipatory grieving

Although the primary physician and various specialists explain the diagnosis and prognosis to Mr. Masden and offer palliative treatment, the message he receives differs from the message they’ve delivered. He believes radiation therapy for the Pancoast tumor and I.V. immune globulin (IVIG) for Lambert-Eaton syndrome are curative rather than palliative. Nursing interventions include listening actively, offering empathy, and allowing hope.

Mr. Masden chooses to receive IVIG and begin radiation therapy. However, the radiation therapy is off-site, so he must be driven to and from the treatment center in an ambulance. He finds the treatment exhausting and sees no improvement in his condition. As he continues to ask questions of the hospital staff and family members, he gradually begins to understand his poor prognosis. After 1 week of treatment with further deterioration, he decides to discontinue the IVIG and radiation.

Outcome

Mr. Masden lives alone, wishes to die at home with his dog, and has a cousin who can stay with him. He’s receptive to, and accepted, for home hospice. The intake nurse recommends hiring a live-in home health aide as the cousin has no nursing experience. He declines the services of counseling and pastoral care.

The next day, an ambulance takes Mr. Masden home. The live-in home health aide and hospice nurses assist the cousin in providing end-of-life care that meets his preferences. Ten days later, he dies peacefully with his dog and family members at his bedside.

This case study illustrates the importance of continuity of nursing care for a patient facing unexpected death. Excellent nursing care allowed Mr. Masden to work through the stages of death and dying while maintaining dignity and control.

Selected references

Bhimji S, May SK. Pancoast tumor. www.emedicinehealth.com/pancoast_tumor/article_em.htm. Accessed June 18, 2009.

National Institute of Neurological Disorders and Stroke. NINDS paraneoplastic syndromes information page. www.ninds.nih.gov/
disorders/paraneoplastic/paraneoplastic.htm. Accessed June 18, 2009.

Visit www.AmericanNurseToday.com/Archives.aspx for a complete list of selected references.

Claire P. Donaghy is a an associate professor at William Paterson University in Wayne, New Jersey, a nurse practitioner with Hawthorne Family Practice in Hawthorne, New Jersey, and a per diem staff nurse at Saint Clare’s Hospital in Denville, New Jersey.