Patient Care at the End of Life

Patient Care at the End of Life Chat Transcript with Charles Loprinzi, MD
Tuesday, February 22, 2005, 2:00 - 3:00 PM ET

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Patient Care at the End of Life, a live question-and-answer session hosted by Charles Loprinzi, MD.

During this hour, Dr. Loprinzi will answer as many questions as possible. Due to an increasing number of chat participants and number of questions submitted for each chat event, time simply does not allow us to address all of your questions, and we encourage you to consult your doctor and cancer care team.

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Good afternoon and welcome. Thank you for joining us. Dr. Loprinzi will now begin taking questions.

Charles Loprinzi, MD, is currently the Chair of the Medical Oncology Division at the Mayo Clinic Cancer Center, and Professor of Oncology at the Mayo Clinic College of Medicine.

Dr. Loprinzi is certified in medical oncology by the American Board of Internal Medicine, and is certified a Diplomate by the National Board of Medical Examiners. Dr. Loprinzi has published numerous articles on the side effects of cancer and its treatment, and is on the editorial boards of multiple medical journals.

Dr. Loprinzi, thank you for taking the time to join us today.

Dr. Loprinzi: Good afternoon. I am pleased to participate in this chat about a very real, and at times very emotionally difficult, subject matter. As I tell my patients, my philosophy with tough issues is to be honest with the facts and not try to hide behind any difficult issues. I will act the same way in this chat.

Let me discuss, up front, a project that I have been involved in over the past five years, which is now available to you on the Cancer.Net website. The project is titled, The Art of Oncology: When the Tumor is Not the Target. This is a series of articles that was published in January 2000 in the Journal of Clinical Oncology, the major journal read by clinical oncologists around the world.

This series was initiated to facilitate discussion of, and improvement in, end-of-life care issues by oncologists. It had been recognized, in the late 1990s, that oncologists could improve the care of patients as patients approach the ends of their lives. It was hoped that this series could facilitate this process.

As the series developed, it also developed into a series to deal with communication issues between oncologists themselves, and between oncologists and their patients. It also has served to allow a forum for oncologists to discuss emotional issues as they deal with their practice.

This series was edited with the thought that the material is applicable to the lay public. While the articles do contain some medical jargon, experience to date has demonstrated that they are largely understandable by non-medical audiences. To this end, Cancer.Net has made them available.

To get to these articles, many of which I am likely to refer to in the following discussion, the following pathway is provided: cancer.net => Coping(left-hand side) => In Their Own Words => The Oncologist's Perspective => four subsets are provided and the individual articles can be found under one of these subsets.

With this, I am pleased to take questions.

Guest46: No one wants to talk about pain at the end of life. Can someone discuss what kind can be expected? What kinds and intensity might be expected?

Dr. Loprinzi: Let me start by mildly disagreeing with the first comment, that being that, "No one wants to talk about pain at the end of life." This might be modified to say, "Many do not want to talk about pain at the end of life." This is because there are some dedicated people who do take the time to address this issue.

If a patient and his or her family note that the major goal is to control pain at the end of life, and a team is directed to work toward this goal, then pain can almost always be controlled. In general, control of pain in this situation should take minutes to hours, as opposed to days to weeks.

In order to adequately control pain at the end of life, appropriate mechanisms need to be set up ahead of time. In general, hospice care has the best means of addressing pain at the end of life. The goal of hospice is to try to have a patient do as well as possible for as long as possible, neither trying to "chasten death" nor "prolong life." With this thought in mind, medications are available to make the patient comfortable. It must be noted, sometimes this control of pain may decrease the level of consciousness of a patient. This, however, can be a welcome relief to severe pain.

Please note the following articles in the Art of Oncology series dealing with hospice care:

"Discussing Hospice" by Charles F. von Gunten: How does a physician talk to a patient about referral for hospice care? Dr. von Gunten provides a step-by-step discussion of how to sustain hope and discusses the benefits of hospice care in such a situation.

"Overcoming Obstacles to Hospice and Palliative Care: An Ethical Examination of Inertia and Inaction" by Christopher Daugherty and David Steensma: Why is it that many patients are not referred for hospice care at the end of their lives? What are the social and ethical ramifications of such decisions?

"An Existential Oncologist" by Lidia Schapira: How does an oncologist deal with the bureaucracy of medical practice, and the fear of litigation? How, also, do practice experiences allow an oncologist to evolve his or her personal self?

"Interventional Pain Therapy for Intractable Abdominal Cancer Pain" by David P. Seamans, Gilbert Wong, and Jack Wilson: This piece describes the potential benefits of intrathecal morphine in a selected patient who had severe pain despite large doses of systemic opioids.

Guest41: Why does a dying person sweat profusely, even though they are very cold to the touch?

Dr. Loprinzi: In my experience, it is not a common scenario for a dying person to sweat profusely. Nonetheless, this can occur just as it can be in a patient who has fever and chills. When they are chilling and sweating, they can be cold and clammy.

Guest216: Does giving fluids to a dying patient really make them more uncomfortable?

Dr. Loprinzi: The utility of intravenous fluids in a patient on hospice care is a subject of much debate. This is especially true the closer a patient is toward his or her own death. At times fluid administration can lead to more swelling in various parts of the body and more secretions.

In general, the hospice approach is to not utilize intravenous fluids given this lack of any proof of benefit in improving the quality of life or quantity of life of patients in this situation. This is especially true if a patient has swelling in their extremities. Generally, patients approaching the end of life are not complaining of being thirsty.

If they are, then providing moisture to their mouth and lips oftentimes will relieve such feelings. The following article is recommended to address this issue:

"To Hydrate or Not to Hydrate: How Should It Be?" by Eduardo Bruera and Neil MacDonald: This essay discusses the potential benefits, along with the potential downsides, associated with providing systemic fluids to patients who are dying from advanced cancer.

Guest13: Are all people happy with their hospice decisions?

Dr. Loprinzi: It's easy to answer this question. The short answer is, "No." That's because there is virtually nothing in which all people will be "chappy." Having said this, in my experience, about 90% to 95% of patients who go on hospice are extremely pleased with their decision.

Patients' families are also pleased around 90% of the time. Evidence of this is noted by looking at obituaries and noting how often donations are suggested for a particular hospice.

Please note the articles referenced above with regard to hospice.

Guest45: What financial and counseling services are available to help long-distance caregivers?

Dr. Loprinzi: In admitting the limits of my knowledge about certain subjects, my recommendation would be to contact a social worker to try to address these questions. They would be best equipped to know the resources that may, or may not, be available in various situations.

Guest14: Would you kindly discuss the dimensions of cross-cultural variables in approaching end-of-life issues?

Dr. Loprinzi: This is a very complex question with many ramifications. Let me refer you to the following articles:

"Allowing Patients to Die: Practical, Ethical and Religious Concerns" by Marc J. Kahn, Cathy J. Lazarus, and Donald P. Owen: At times, patients have resolved, in a fully rational manner, that it is time for them to stop eating and let nature take its course. Should they be allowed to do such?

"Spirituality and Religion in the Art of Dying" by Lois Ramondetta and Deborah Sills: The title of this article nicely describes its content.

Guest559: I have been caring for my parents for five years. Recently, my Dad was diagnosed with an aggressive brain tumor. I am expecting my fourth child and it's increasingly becoming difficult to care for my Dad. What sorts of in-home or nursing home care alternatives might be available for my Dad in his last stages of life?

Dr. Loprinzi: This is a difficult situation. Support from many sources may be available. Such sources might include other family members, a church family, or you may want to contact social services from the health-care institution that is taking care of him.

The best way, however, is to have hospice help and get direction from them.

Guest42: How do you feel about talking about end-of-life issues at the time of diagnosis? What might be the benefits/drawbacks?

Dr. Loprinzi: This is a very good question. The answer depends on a number of factors, including the desires of the patient, the disease situation, and the goals of the therapy. For example, if a patient has a very small, newly diagnosed cancer with a 90% cure rate from therapy, then there does not appear to be any need to address these sorts of issues, unless the patient really wishes to do so.

On the other hand, if a patient presents with an advanced, incurable, cancer with a short life expectancy, then addressing these issues is much more reasonable. The following articles are recommended:

"Caring For Dying Patients: What is Right?" by Mary Bretscher: What happens when a patient with far-advanced cancer is not told about end-of-life issues? This piece illustrates the end result of such a scenario and provides insights as to how different groups (patients, bereaved individuals, professional caregivers, and personal and family caregivers) think about end-of-life care issues.

"Doc, How Much Time Do I Have?" by Charles L. Loprinzi, Mary E. Johnson, and Gretchen Steer: How do experienced oncologists address the question, "Doc, how much time do I have?" To provide better insight into this issue, this manuscript describes a role-play situation in which seven different experienced physicians provide their answers to this piercing question.

"A Revisitation of 'Doc, How Much Time Do I Have?'" by Lidia Schapira, Peter D. Eisenberg, Neil MacDonald, Matthew P. Mumber, and Charles L. Loprinzi: The previous essay evoked responses from members of the oncology community which were then put together into a subsequent piece to further discuss how physicians should address the question, "Doc, how much time do I have?"

"Tell It Like It Is" by Thomas J. Smith: Dr. Tom Smith describes his clinical practice of providing patients with written information to honestly tell them their diagnosis, their prognosis, and to outline the goals of potential treatment options, including cytotoxic therapy and supportive care. This honest presentation of data provides patients with the ability to make better-informed decisions regarding their care.

"The Day One Talk: Example of the Delivery of Bad News" by Jennifer W. Mack and Holcombe E. Grier: This piece, written from a pediatric oncology prospective, discusses a good way to communicate with children and their families from the beginning.

Guest293: Our friend has breast cancer that has spread to the brain. We thought the brain tumors had been treated, but possibly they recurred. Her doctor recommended she quit her job, go on disability, and get home care. Does this mean there may be no hope for her?

Dr. Loprinzi: Without being able to state for sure what the situation is, it sounds like this is a circumstance where the doctors have determined that anticancer therapy (for example, with surgery, radiation, or chemotherapy) will not facilitate the goals of helping this patient "live as well as possible, for as long possible."

Again, this is the goal of treatment for a patient with cancer that is considered to be incurable. The last sentence of your question rings true with how I think about things. It is important to "hope for the best but to prepare for the worst." In this situation, it is important that hope not be lost. Rather, the expectations of hope need to be adjusted as disease progresses. For example, in a patient first diagnosed with cancer, they may hope that they really don't have the cancer.

Next, they may hope that the cancer can be cured. If the cancer then comes back, they may hope that the cancer can be controlled for as long a period as possible. When there is no further anticancer therapy, the hope may change to being comfortable at the end and also in having things set for family and friends when the patient is no longer there.

The following piece is recommended for you:

"Setting Goals to Maintain Hope" by Jamie H. Von Roenn and Charles F. von Gunten: In patients with advanced, incurable cancer, hopes, realities, and goals ideally need to be brought in synch. There are skills to make this happen.

Moderator: Transcripts of today's chat will be available Wednesday, February 23, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

Guest352: Why is a certain little pill given to a lung cancer patient for the "death rattle?"

Dr. Loprinzi: "Death rattle" is a term that has been used in the medical literature. It is not one that sounds very flattering, and thus it is not often used by health-care providers when discussing things with patients and families.

Nonetheless, it refers to a situation whereby patients who are unconscious and near death develop a rattling noise with their breathing. This is due to a build up of secretions in the back of the throat. The patient is not alert enough to clear the secretions.

While there is no convincing evidence that patients suffer from the situation (because they are unconscious), this can be a very disconcerting symptom for the rest of the family. There are some medications (for example, atropine) that can be given to the patient to dry up these secretions. This medication can be given as a pill or as some drops. The drying up of secretions can resolve this gurgling sound.

Beth: My husband lost his father to cancer a year ago. Not only has it been difficult to grieve along side of him, but it has also taken a huge toll on our marriage, as he has remained more distant and removed. I could use some advice.

Dr. Loprinzi: It is not easy dealing with the loss of a loved one. The term that's been given is bereavement. It often takes a year or longer for somebody to appropriately grieve a loss like this.

One of the articles in the Art of Oncology series is an excellent piece written by a physician as he talks about grieving for his wife who died of breast cancer.

This article is as follows.

"On the Death of a Spouse: Reflections of a Medical Oncologist" by Peter A. Beatty: This piece describes the lessons learned by a medical oncologist after his spouse died from metastatic breast cancer.

Guest716: I am faced with watching my oldest son struggle with cancer. Do children face death differently (in physical terms) from adults? I was with my father when he passed from a stroke. Do they face death differently?

Dr. Loprinzi: This is not an easy situation. Many parents would much rather have cancer themselves as opposed to their child having it.

There are many different ways that people face cancer. This applies to both adults and children. It is not clear that children face death differently than adults.

One of the pieces of the Art of Oncology series actually deals with talking to children about their cancer. It might be helpful for you.

"Tell the Children" by Joanne Hilden, Jan Watterson, and Jody Chrastek: Should children, and their siblings, be told that death is imminent, when that is the truth? This piece explains the benefits of being honest and truthful with patients in this situation, even if they are "just children."

Guest31: As a sister of someone who is dying from cancer, how can I encourage my family who does not want to talk about the imminent death of my brother, who is only 45 years old with two young children?

Dr. Loprinzi: There is no one single answer that fits this question. In general, allowing open-ended conversation is recommended. Oftentimes, this is a one-on-one conversation as opposed to a group discussion.

If hospice is involved, they could be resourceful in addressing this issue.

Guest461: My wife of 40 years has been given six months to live and our grown children live far away. I feel lost at times about this situation. What is the best reading information to help a person deal with all the issues that this situation forces one to think about?

Dr. Loprinzi: Let me start by saying that feeling lost in this situation is not an unusual circumstance. Neither you nor your wife has had to do anything like this before, in all likelihood. The best reading information is cited in many of the articles referenced above.

You may wish to look at the whole series that is provided, through the links discussed in my introductory comments above. Specific ones that have not been mentioned above, but may be of help are as follows:

"Discussing Do-Not-Resuscitate Status" by Charles F. von Gunten: How does a physician talk to a patient with advanced cancer about what should be done when that patient dies? A step-by-step process for teaching this skill is provided in this entry.

"Challenges in Outpatient End-of-Life Care: Wishes to Avoid Resuscitation" by Jessica P. Hwang, Martin L. Smith, and Anne L. Flamm: Many patients with advanced cancer choose not to undergo resuscitation in the event of a life-ending event. How is this communicated to others when they are outside of the hospital?

"Simultaneous Care: Disease Treatment and Palliative Care Throughout Illness" by Frederick J. Meyers and John Linder: Ideally, patients can receive optimal palliative care and continue to receive "anticancer treatment." This, however, is not always easily done. Dr. Meyers and Dr. Linder discuss ways to make this happen.
"Addressing Spiritual Care: Calling for Help?" by C. John Steer and Chris Lee: This piece addresses the role of chaplains and ministers in preparing for patients with cancer.

"A Couple with Cancer" by Bodga Koczwara and Matthew M. Clark: Cancer affects more than just the patient; it impacts other family members, too. This piece discusses how personalities of patients and spouses influence cancer care.

"Dignity and the Eye of the Beholder" by Harvey M Chochinov: Some patients at the end of life lose dignity. Dr. Chochinov nicely describes a helpful method to try to resurrect dignity in such patients.

"Treatment Decision Aids in Advanced Cancer: When the Goal is Not Cure and the Answer is Not Clear" by Natasha B. Leighl, Phyllis N. Butow, and Martin H. N. Tattersall: What are the best methods for honestly communicating with patients regarding the pros and cons of chemotherapy and other anticancer treatments when curing a patient is not a reasonable goal?

In addition, although this might not be particularly applicable to your particular situation with adult children, the following piece discusses such issues with children.

"Parents with Cancer: Who's Looking After the Children" by Paula K. Rauch, Anna C. Muriel, and Ned H. Cassem: What is done or should be done, for the children of patients with cancer, particularly when a parent may have an advanced incurable cancer? This essay provides practical advice for patients and their family caregivers with children.

Guest84: What do you view as the best way to break "bad news" to the patient?

Dr. Loprinzi: Breaking bad news is not oftentimes an easy endeavor. It is a skill that some people naturally have, but many do not. It is, however, a skill that can be taught.

Several pieces in this series do deal with this issue. These pieces, with a description of each, are as follows:

"Tell It Like It Is" by Thomas J. Smith: Dr. Tom Smith describes his clinical practice of providing patients with written information to honestly tell them their diagnosis, their prognosis, and to outline the goals of potential treatment options, including cytotoxic therapy and supportive care. This honest presentation of data provides patients with the ability to make better-informed decisions regarding their care.

"Setting Goals to Maintain Hope" by Jamie H. Von Roenn and Charles F. von Gunten: In patients with advanced incurable cancer, hopes, realities, and goals ideally need to be brought in synch. There are skills to make this happen.

"Teaching Communication Skills to Medical Oncology Fellows" by Anthony L. Beck, Robert M. Arnold, James A. Tulsky, Walter F. Baile, and Kelly A. Fryer-Edwards: Communication about difficult life-altering issues does not necessarily come naturally. These skills, however, can be taught.

"Giving Bad News to Cancer Patients: Matching Process and Content" by Walter F. Baile and Estela A. Beale: How is bad news shared with cancer patients? This manuscript discusses this issue, primarily from a psychologic standpoint.

"Fellow Suffering" by Jennifer Armstrong: How do oncologists in training deal with the reality that many of their patients die from the cancer process? Is there a way to provide them tools to better cope?

Guest402: I am taking care of a dear friend who is 60+ years old with recurrent liver cancer. Her doctor has given her three to six months to live. What are the last stage symptoms to look for? What will she experience? Will she experience pain? She is now vomiting and has a high fever.

Dr. Loprinzi: There are several things that might happen, with it being impossible to know for sure for a specific patient. Nonetheless, in general, patients like this die from liver failure. Nausea and vomiting can be a symptom from this early on; her nausea and vomiting hopefully can be controlled with medications like prochlorperazine (Compazine) or haloperidol (Haldol).

Some patients will have trouble with fever related to cancer. While the doctors may try to rule out some sort of infection also, a medication like ibuprofen can oftentimes help decrease the fever associated with cancer.

In general, patients who have liver failure do not experience a lot of pain. The exception to this is that sometimes there are relatively short periods of intermittent pain (when the cancer stretches the liver capsule acutely). Generally, pain medications can be utilized for a couple of days to control this sort of pain.

Usually, patients who die from liver insufficiency have more trouble with fatigue, weight loss, and appetite loss. This decreases the activity of the patients, so they spend more time in a chair and then more time in bed. Toward the end, they may become jaundiced (yellow colored). They often become comatose for hours to days before death.

If the patient in this situation wishes to be at home, hospice care can be valuable.

Guest200: I serve as a chaplain in our hospital that has chemotherapy and radiation treatment facilities. As we develop our services here, what might you say about the role of spiritual and religious care with the person who is living with cancer?

Dr. Loprinzi: There is certainly a role for spiritual care of the patient living with cancer and those who die from cancer. The minister of my church is happy to note that several manuscripts in the Art of Oncology series have dealt with this issue. The following pieces are recommended:

"Allowing Patients to Die: Practical, Ethical and Religious Concerns" by Marc J. Kahn, Cathy J. Lazarus, and Donald P. Owen: At times, patients have resolved, in a fully rational manner, that it is time for them to stop eating and let nature take its course. Should they be allowed to do such?

"Addressing Spiritual Care: Who Can be Called for Help?" by C. John Steer and Chris Lee: This piece addresses the role of chaplains and ministers in preparing for patients with cancer.

"Spirituality and Religion in the Art of Dying" by Lois Ramondetta and Deborah Sills: The title of this article nicely describes its content.

"Spirituality and the Dying Patient" by Paul Rosseau: This article discusses how the provider should evaluate and treat spirituality issues in patients with life-threatening disease.

Guest000: How do oncologists deal with the emotional issues of caring for patients with cancer?

Dr. Loprinzi: Let me start by saying that taking care of oncology patients is a real and distinct pleasure for most oncologists.

This patient group is, on the whole, a very appreciative group. They are grateful for what help can be provided for them. Nonetheless, taking care of patients with life-threatening illnesses can become emotionally charged experiences for physicians and other health-care professionals.

While, on one hand, these experiences can be taxing, they also allow for personal growth of the involved parties. The following pieces in this series discuss various aspects of this issue:

"The Narrow Path" by David Steensma: How close should oncologists get, emotionally, to their patients? Should they become intimately involved with their patients or, alternatively, should they remain emotionally distant? The path indeed may be narrow as a physician tries to walk between these two ends of the spectrum.

"Submitting to Autonomy" by David Steensma: What should a physician do if a patient does not follow medical advice that, in the physician's judgment, will likely lead to more problems in the future? At times, physicians need to submit to patient autonomy, even if the patient may make a decision that makes the physician uncomfortable.

"Why Me?" by David Steensma: Patients afflicted with terrible diseases frequently ask, "Why me? Why did I get this disease?" What do they mean when they ask such a question? How does a physician respond?

"Reassurance" by David Steensma: How can oncologists appropriately and honestly reassure patients when prognosis is quite poor.

"Pulling the Trigger" by Frank L. Meyskens, Jr. and John H. Fetting: Oncologists are asked to practice euthanasia (mercy killing) at times. How do oncologists respond to such a request?

"When Your Favorite Patient Relapses–Physician Grief and Well-Being in the Practice of Oncology" by Tait Shanafelt, Alex Adjei, and Frank L. Meyskens: How do physicians react when patients don't do well? How can they protect themselves from burnout?

"Can you cure him for the baby's sake?" by Paulette Mehta and John Fetting: Some patients wish to have chemotherapy despite all odds against it working. This piece addresses this issue.

"On the Death of a Spouse: Reflections of a Medical Oncologist" by Peter A. Beatty: This piece describes the lessons learned by a medical oncologist after his spouse died from metastatic breast cancer.

"Fellow Suffering" by Jennifer Armstrong: How do oncologists in training deal with the reality that many of their patients die from the cancer process? Is there a way to provide them tools to better cope?

"Just Whose Autonomy Is It?" by Mellar P. Davis, Deborah Davis, Martin Smith, and Kathleen Cooper: Is it the patient's right to hoard narcotics, so they could be utilized for a suicidal attempt? What if this information is shared with the health-care team? How is autonomy defined in such a case?

"The Right to Decide" by Sarah Friebert and Eric Kodish: Does a patient have the right to decide that they would like to have a "no code" status, even if the treating physicians feel that aggressive care is indicated because the may have a curable malignancy? This emotionally charged issue is reviewed, utilizing a true case example.

"Taking Time" by David N. Korones: This is a heartfelt story about oncologists encouraging other physicians to take time to learn about how patients are in the world away from the oncology office.

"Looking at the Dying Patient: The Ferdinand Hodler Paintings of Valentine Godé-Darel" by Bernhard C. Pestalozzi: This piece is primarily a visual one. Seven paintings by a Swiss painter (Ferdinand Hodler 1853-1918) are illustrated. These pictures, regarding his wife, were drawn before, during, and after her illness with a fatal gynecologic cancer.

"An Existential Oncologist" by Lidia Schapira: How does an oncologist deal with the bureaucracy of medical practice, and the fear of litigation? How, also, do practice experiences allow an oncologist to evolve his or her personal self?

Guest64: Can you please give me some guidance with regard to how much to tell my 7 year old about his grandmother's cancer? She is in hospice care and given only months to live. She is also a primary figure in his life.

Dr. Loprinzi: The most important thing here is to discuss the issues as openly as possible. Ask the child what questions he might have. It is quite reasonable to ask a child what he is thinking about things.

Having him be around his grandmother is good in this situation. Some families have a tendency to shield children from dying relatives.

It is generally felt best to allow them to be close to such people. A good article regarding this topic is the following:

"Parents with Cancer: Who's Looking After the Children" by Paula K. Rauch, Anna C. Muriel, and Ned H. Cassem: What is done or should be done, for the children of patients with cancer, particularly when a parent may have an advanced incurable cancer? This essay provides practical advice for patients and their family caregivers with children.

Ben: Can you please explain the appropriate steps to follow should someone die at home? We want to preserve dignity in every possible way.

Dr. Loprinzi: Two to three decades ago, it was relatively rare for people to die at home. Instead, they commonly died in institutions. Nonetheless, if most people are asked where they would like to die, the majority says they would rather be at home.

Hospice care is of the utmost benefit in this situation. Many think that having a person die at home is a tremendous amount of work for the family. I like to tell families in this situation that, with hospice help, having a patient die at home is generally no more difficult than having a newborn baby at home.

This is not to say that having a newborn is not a lot of work, but rather it is work that can be done. Such a situation is often one that brings a family unit together and provides much satisfaction for the remaining family members.

I know that this was true in my own personal situation when my father died at home with hospice care.

Moderator: The chat is now ending. Thank you for your thoughtful questions.

We hope this discussion has been valuable, and we regret not being able to answer every question. We want to thank Dr. Loprinzi for lending us his time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) Wednesday, February 23, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net for a live chat about Cancers of the Gastrointestinal System on Thursday, March 31, 2005, from 3:00 - 4:00 PM ET.

The featured expert is Richard Schilsky, MD, of the University of Chicago.

The chat room is now closed. Thanks again for joining us.

Last Updated: February 23, 2005