From the Department of Anesthesia, Baylor College of Medicine, Houston, Texas.
Accepted for publication August 14, 2013
Funding: Not funded.
The authors declare no conflicts of interest.
Address correspondence to Lisa Mouzi, MD, Department of Anesthesia, Baylor College of Medicine, 333 East 34th St., New York, NY 10016. Address e-mail to firstname.lastname@example.org.
Cancer complicating pregnancy is an infrequent occurrence, but when the 2 coexist, the therapeutic goals for both the mother and the fetus need to be considered. Sometimes, the therapeutic goals of the mother and the fetus conflict. It is the current position of the American Medical Association, the American College of Obstetricians and Gynecologists, and the International Federation of Gynecology and Obstetrics to respect a woman’s autonomy, allowing her to make informed decisions during her pregnancy.1,2 Given the specialized training for anesthesiologists in pain management, we can have a very powerful role in the multidisciplinary team management of the terminally ill pregnant patient. We must remind our colleagues of the obligation to keep terminally ill patients comfortable during their end of life, and we must be patients’ advocates if it seems that their best interests are being overlooked.
The patient’s power of attorney gave written permission for the authors to publish this report.
The patient was a 35-year-old G7P5 Hispanic woman, with a history of noncompliance, polysubstance abuse, depression, and stage 4 metastatic breast cancer, who had been admitted multiple times over the past several months for shortness of breath, hemoptysis, and chest pain. She was readmitted at 31 2/7 weeks for expectant management of her pregnancy.
The patient initially presented with a 10-month history of an enlarging left breast mass diagnosed as invasive ductal carcinoma. After being lost to follow-up for 9 months, she underwent left modified radical mastectomy. For the next 2 years, she was noncompliant with her cancer management, and as per current presentation, she had multiple necrotic left chest wall masses, diffuse pulmonary metastases with a 1.4-cm left mainstem endobronchial mass, and extensive liver and mediastinal lymph node involvement.
At 31 2/7 weeks, she was admitted from hospice for management of her pregnancy. On admission, a discussion was held with the patient and her obstetric, maternal-fetal medicine, and internal medicine physicians, and her code status was changed from “Do Not Resuscitate” to “Full Code.” In the event of possible cardiopulmonary arrest, resuscitation would occur while a stat perimortem cesarean delivery would be performed to rescue the newborn. The patient also agreed to the possible need for general anesthesia if the fetal condition suddenly and rapidly deteriorated. IV steroids were administered for fetal lung maturity in anticipation of a preterm birth. During most of her antepartum care, the patient was very restless and uncooperative; she frequently became anxious from hemoptysis, air hunger, and discomfort. During her coughing spells, she became hypoxemic, and her oxyhemoglobin saturation decreased to the mid-80s, further contributing to her agitation. The psychiatry service managed her pain and anxiolysis, which included scheduled doses of buspirone and prn dosing of morphine and lorazepam. Her scheduled doses of opioids were withheld in an attempt to prevent fetal respiratory and central nervous system depression.
At 33 5/7 weeks of gestation, the patient developed severe preeclampsia based on increased arterial blood pressure and mild proteinuria (474 mg/24 hours). Her obstetrical team started a magnesium infusion, induced labor with oxytocin, and artificially ruptured her membranes. Her systolic blood pressures ranged from 130 s to 170 s, and a radial arterial catheter was inserted. Given her poor pulmonary reserve from her pulmonary and endobronchial lesions, and her requirements for 6 to 10 L of oxygen per venturi mask, labor epidural analgesia was initiated for pain relief and to improve respiratory mechanics during uterine contractions. Over the next 24 hours, epidural analgesia was initially maintained with a continuous infusion of 0.0625% bupivacaine with fentany l 3 µg/min at 16 mL/h and then increased to 0.125% bupivacaine with fentanyl at 14 mL/h to treat breakthrough pain. Decreased variability in the fetal heart tracing led her obstetricians to discontinue her prn morphine and lorazepam, because there was a temporal relationship between the administration of the medication and the nonreassuring fetal status. This augmented the patient’s anger and hostility and complicated her management further. She became uncooperative and complained of worsening generalized body pain. Ultimately, the patient’s agitation and distress led to her pulling out her arterial catheter, her intrauterine pressure catheter, and fetal scalp monitoring electrodes and threatening to leave the hospital against medical advice.
After >24 hours of labor induction, a prolonged late deceleration led to a stat cesarean delivery. Rapid sequence induction was performed, and the patient’s trachea was intubated without complication. The baby was delivered within 2 minutes after induction with APGAR scores of 7 and 8 and was immediately taken to the neonatal intensive care unit. The patient was hemodynamically stable throughout surgery that included bilateral tubal ligation. Although her PaO2 was 307 mm Hg while breathing 100% FIO2, her trachea remained intubated, allowing for a gradual process of separation from the ventilator. Her code status was changed to “Do Not Resuscitate” for the remainder of her hospital stay by her medical power of attorney. Her trachea was extubated within 1 week, and she was discharged back to hospice care, where she died in the subsequent weeks.
Cancer occurs in the mother in approximately 1 per 1000 live births.3 Curative protocols during pregnancy, including radiation and chemotherapy, are described widely in the literature and are prescribed even in the face of teratogenesis and the possible need for medical interruption of pregnancy. Interestingly, however, palliative care tends to stir much more controversy than do curative treatments of cancer in the pregnant patient.4 Palliative care for pregnant women is especially challenging because of the conflict between the needs of the mother and her fetus. To what extent is it permissible to curtail or altogether withdraw pain-alleviating, comfort care measures to the detriment of the mother to favor survival of the fetus?
For most pregnant patients, the welfare of the fetus is the utmost priority. Most adopt positive lifestyle habits in the form of healthier diets while others discontinue negative practices such as alcohol and tobacco use with the goal of providing the most beneficial environment for the growing fetus. In some instances, however, the interests of the mother and the fetus diverge. In these cases, it is the opinion of the American College of Obstetricians and Gynecologists that the pregnant woman’s autonomous decisions should be respected.5
Currently in the United States, fetuses have no legal rights. Internationally, finding legal grounds for the concept of fetal rights has been unsuccessful. Both the Convention of the Rights of the Child and the American Convention on Human Rights offer protection of children before birth but do not prioritize their welfare over the life and health of born persons.6 The concept of the fetus as a separate independent patient in many ways can be a benign way to consider the implications that various treatment modalities for the mother can have on a developing fetus. Thus, it is intended to prevent inadvertent harm. However, for a physician to deny treatment or provide a treatment against the will of the mother for the sake of the fetus is not only a betrayal of trust but can be grounds for professional misconduct.6
In this case, the patient was terminally ill, and her end-of-life treatment was being managed by hospice care until the weeks before delivery. She was receiving a regimen consisting of opioids, benzodiazepines, and antidepressants to manage her generalized body pain and anxiety. Once she was hospitalized for expectant management of her delivery, attempts were made to keep her comfortable initially but waned later in favor of protecting her unborn baby. According to standard palliative care principles, advanced illness warrants a regimen of scheduled pain medications, including but not limited to short- and long-acting opioids.7 Because she had been receiving opioids long term, there was concern that our patient and possibly her fetus developed dependence. Abrupt discontinuation of an opioid can cause unpleasant side effects, including agitation, restlessness, hypertension, and tachycardia, among others. It is quite possible that in this case, the diagnosis of severe preeclampsia based on her extremely increased arterial blood pressures, but only mild proteinuria, may have masked possible opioid withdrawal. Thus, in this case, it would have been more prudent to continue the patient’s opioid therapy despite fetal depression.
This patient was not only suffering from chronic cancer-related pain but also intractable dyspnea. According to data from the National Hospice Study, 75% of patients with lung or pleural involvement from their disease experience dyspnea during their last 6 weeks of life. In patients who had no history of cardiac compromise or lung involvement, the incidence of dyspnea during end of life approached 24%.8 Dyspnea is a subjective feeling of shortness of breath that many times has psychological underpinnings that can be aggravated by anxiety and depression. The diagnosis of dyspnea is based on the reported symptoms of the patient because measurements of respiratory rate, pulse oximetry, and arterial blood gases do not correlate with its degree.9 The best means to manage dyspnea is to treat the underlying cause. Beyond this, the mainstay of symptomatic control is opioid therapy, anxiolytics, and oxygen therapy.7
Anesthesiologists play a key role in the management of high-risk pregnancies. In addition to administering advanced life support, they are responsible for providing analgesia and comfort measures to their patients. The treatment of critically ill obstetric patients requires a multidisciplinary approach that balances proper pain management and sedation in the mother with the physiologic concerns of the fetus. Occasionally, physicians err on the side of caution to protect the fetus, and in turn, inadequately treat the mother. This can counterproductively lead to feelings of doubt and distrust toward the physician, as in this case. The authors suggest that in this situation, physicians should have instead ensured appropriate pain control, anxiolysis, and comfort measures to the best of their ability in the mother to help ease the emotional and physical burden during very grim clinical and emotional circumstances.