User login
Managing Requests for Medical Aid in Dying Within the Veterans Health Administration
Managing Requests for Medical Aid in Dying Within the Veterans Health Administration
Requests for medical aid in dying (MAID) within the Veterans Health Administration (VHA) present unique ethical, legal, and clinical challenges. MAID is a process in which a physician provides a terminally ill patient with the means to end their own life. It is expressly prohibited by federal law, including within the US Department of Veterans Affairs (VA), regardless of its legality at the state level.1 MAID is also prohibited within community care institutions funded by the VA. The American Medical Association, American Geriatrics Society, and American Academy of Hospice and Palliative Medicine have adopted neutral positions regarding MAID due to varying opinions among their respective members.2-4 VHA palliative care clinicians are trained to identify and honor preferences for care and alleviate physical and emotional distress, which may complicate the management of MAID requests. Veterans can request MAID due to their desire for autonomy and pain relief, but the VHA prohibits clinicians from honoring these specific preferences. The inability to help veterans achieve their care preferences conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.
This case report describes the management of a veteran who requested MAID while also exhibiting active suicidal ideation. The patient’s distress stemmed from fears of impending loss of autonomy and functional decline, factors frequently linked to requests for MAID in terminally ill patients.5,6 Addressing the veteran’s request for MAID required balancing respect for patient autonomy and concerns about future suffering with the VA mission to protect veterans from self-harm and provide mental health care for suicidal ideation. This case highlights the importance of nuanced clinical approaches, ethical reflection, and interdisciplinary collaboration in navigating such complex scenarios. Informed consent was obtained from the patient’s family and health care agent (HCA) to publish this report.
Case Presentation
A 73-year-old male veteran, with Parkinson disease (PD), diagnosed at age 52 years, was referred to palliative care following diagnosis of a glioblastoma multiforme (GBM). The patient also had a history of major depressive disorder (MDD), suicidal ideation (SI), benign prostatic hypertrophy, and migraines. He was divorced, had no children, and his only sibling (sister) was deceased. His brother-in-law served as his HCA.
The patient had many close friends in the community, was an architect by training, and was active in the removal of barriers and increasing access for people with disabilities. Since 2010, about 7 years before his PD diagnosis, the patient used psychiatry and psychology resources to treat MDD, functional decline, and SI. He was hospitalized in 2016 after self-administration of heroin. During the hospitalization the patient received a high risk for suicide label. He articulated a firm and long-standing belief in his right to die and shared plans to end his life when he experienced a significant decline in his independence and quality of life (QoL).
When diagnosed with PD, the patient shared that his QoL was of utmost importance. He was aware that he would have significant physical decline as PD progressed and felt like there would be a point when his QoL would not be acceptable. When that happened, he wanted to end his life by available means. He was followed closely by his VHA care team for physical and emotional distress.
When diagnosed with a GBM in 2023, the patient declined treatment and was referred to palliative care, which had sporadically treated him for PD-related distress prior to 2023. During his previous palliative care visits, the patient had discussed a desire to engage in MAID when his functional status declined. After the GBM diagnosis, he reported no acute intent to harm himself with heroin, but planned to travel to Vermont for MAID when he felt he no longer had an adequate QoL based on functional capability.
Pharmacologic and nonpharmacologic approaches were used to treat the patient’s pain. He reported significant benefit from biofeedback therapy provided by the VA Headache Center of Excellence. This work also reconnected him to meditation, which he used daily to relieve pain and distress. The patient managed head pain with nonpharmacologic and pharmacologic interventions for 6 months and reported satisfaction with his QoL.
After 6 months, imaging showed progression of the brain tumor, which was associated with more fatigue and memory decline. At that time, the patient was enrolled in home hospice and reported continued intent to pursue MAID in Vermont but had not taken steps toward carrying it out. The patient understood the VA could not assist him in pursuing MAID; however, his care team was able to assist him in sharing his preferences for care with his loved ones and health care power of attorney.
He experienced rapid functional and cognitive decline due to progression of the GBM and was admitted to the VA Connecticut Healthcare System (VACHS) acute care unit where he exhibited confusion and screened positive for delirium using the Confusion Assessment Method.7 His physical and cognitive deterioration was likely due to the progressive brain tumor, and the patient lacked the capacity to make complex medical decisions. Formal consent was obtained from his HCA to transfer him to inpatient hospice. Psychiatry followed the patient throughout.
After 4 weeks of hospice care, the patient had a witnessed suicide attempt while the nurse was assisting him in the bathroom. The patient attempted to use hospital pajamas to hang himself when he wrapped a hospital gown around his neck and stated he was trying to tie a knot. Due to his confusion and delirium, the patient was unable to express his reasoning for the suicide attempt. He was seen by the Psychiatry service, which determined that his suicide risk was low to intermediate. The Psychiatry service did not recommend a 1:1 safety sitter, but suggested medication changes. Levetiracetam was discontinued, and valproate 500 mg orally twice daily was initiated for seizure prevention.
The hospice team was informed of the suicide attempt and psychiatry recommendations. The suicide prevention team was also updated following this event and agreed with psychiatry recommendations. The patient continued to decline, was no longer able to get out of bed, and had minimal speech. The patient received comfort medications, including intravenous morphine 2 mg and lorazepam 0.5 mg as needed ≤ 4 times daily. He died 8 days later.
Discussion
Chronic medical illness has been associated with increased suicide risk.8-10 The increased risk of suicide in chronically ill patients has been described as having as a bidirectional relationship with MDD, with depression not only increasing the risk of chronic medical illness but new-onset chronic medical illness being associated with new onset depression.11,12 Chronic medical conditions are associated with numerous psychiatric disorders, and the presence of a comorbid psychiatric illness is associated with higher rates of hospitalization, emergency department visits, and increased health care costs.13 Research has found that the association between suicide risk and chronic medical illness remains even after accounting for comorbid mental health disorders.14 This has been postulated to be due to a multitude of interpersonal, behavioral, cognitive, and affective factors (eg, perceived burdensomeness, loneliness, stress, pain catastrophizing, self-criticism).15 Additionally, some researchers have questioned whether suicidality constitutes a distinct mental disorder.16
Patients with cancer are at increased risk for suicidal ideation (including passive death wishes) and suicide attempts.17,18 Recent data indicate that compared with the general population, there is an 85% increased risk of suicide mortality in patients with cancer.19 Studies show the incidence of suicide is greater for individuals with cancer compared with the general population, with standardized mortality ratios ranging from 1.4 to 5.7.20-22
Among patients with cancer, suicide risk is associated with several factors: worse prognosis, older age, male sex, living in a socioeconomically vulnerable environment, and increased communication about suicidal intent prior to death.23-25 Just as the prevalence of suicidal ideation in people with cancer varies widely, reported rates of suicidality in caregivers of patients with cancer range from 2.7% to 71%.17,26 A survey of health care workers indicated the following reasons patients with cancer may die by suicide or seek aid in assisted suicide: social isolation, pain, physical impairment, loss of autonomy and meaning, terminal illness, and psychic distress and desperation.27
As with cancer, patients with PD exhibit increased suicidal ideation compared with the general population.28,29 Two studies found the suicide rate in individuals with PD is about twice as high as it is in the general population.30,31 Among people with PD, male sex, younger age, initial onset of motor symptoms in the upper or both upper and lower extremities, history of depression or any psychiatric diagnosis, delusions, higher levodopa dosing, and urban residence have been clinically correlated with suicide. Jumping has been a frequent method of suicide.30,31
Some research has evaluated the perspectives of loved ones after a patient chooses MAID. A study in the Netherlands found that 92% of relatives surveyed believed that access to MAID improved QoL and reduced pain at the end of life.32 In another, family members of individuals who used MAID reported higher quality on items related to physical symptom control and preparedness for death, compared with individuals who did not pursue MAID or who requested but did not receive it. There were no differences on items assessing connectedness to their loved one, being unafraid of death, level of consciousness, or global quality of death items.33 Another study found no significant differences in depression rates, grief, or use of mental health services among Oregon families whose loved ones died using MAID compared with those who did not.34
The higher suicide rate among terminally ill patients highlights the complex issue of MAID and the right to die. It is important to differentiate between euthanasia and medically-assisted dying. Euthanasia is an act whereby a person other than the patient acts to cause death. In MAID, the patient is provided with a medication that they self-administer. Recent Gallup polls found that > 70% of Americans believe physicians should be “allowed by law to end the patient’s life by some painless means if the patient and his or her family request it.”35
It is important to acknowledge MAID in the context of chronic suicidality, like in the case described in this article. It is imperative not to dismiss reports of suicidality in this population. Ignoring reports of suicidal ideation may lead to decreased access to pharmacologic and nonpharmacologic interventions. It is also important to maintain a timeline of symptom occurrence and to differentiate between chronic suicidality and the desire to die associated with having a terminal illness. A thorough assessment is necessary to assess whether the patient’s decision stems from a calculated decision with preserved capacity or from underlying mental health conditions. Other factors that may lead the patient to a hastened death (ie, pain, poor psychosocial support, delirium, cognitive impairment, incomplete understanding of treatment/prognosis) need to be addressed prior to finalizing choices. In this case, an assessment was performed by psychiatry, psychology, social work, and chaplains to ensure comprehensive evaluation.
The VHA offers resources to assist individuals experiencing suicidal ideation, including suicide prevention coordinators who work directly with veterans and offer consultation to teams working with veterans at risk for suicide. Support for VHA clinicians who treat veterans considering MAID may help address any moral distress. In this case, the care team met early for overnight sign-out, had daily core hospice team meetings, as-needed safety huddles, and weekly care plan meetings to ensure maximal physical and emotional comfort for the patient. These meetings cultivate open, honest, and transparent discussions regarding any staff concerns or personal distress around the plan of care. The VACHS chief well-being officer was also available for all staff.
A systematic review of the impact of MAID on clinicians found that MAID legislation influenced emotional responses. For countries whose MAID legislation emphasized alleviation from pain in addition to terminal illness, clinicians reported more emotional reflection. Whereas, in countries where MAID legislation is stricter and can be applied solely for terminal illness, clinicians reported a stronger and more polarizing range of emotions.36 This highlights the potential influence of the context in which clinicians work on their emotional experience with MAID. Given that MAID is not permitted in the VA, staff members may experience heightened emotional responses. In a survey of US adults, there was an interest in using MAID but there were knowledge deficits regarding the process and legality.37
Legal aspects come into play as well with regards to MAID. Eligibility requires the patient be aged ≥ 18 years, be terminally ill with a prognosis of ≤ 6 months, have the capacity to make their own health care decision, and be able to self-administer the medication. States also may have residency restrictions. Special care and adequate education are needed, as having anyone but the patient administer the medication may be considered criminal. Furthermore, since MAID is not allowed federally, this creates further distress in VHA clinicians entrusted to minimizing pain for patients.
Strategies to support veterans given prohibition of MAID include: conversations about the patient’s values, clarifying reasons for request, assessing all domains of distress, affirming concerns with compassion and nonjudgment, addressing any pain using pharmacologic and nonpharmacologic interventions, providing education on other permissible options for end-of-life care, and consulting other specialties.38
End-of-life options permitted by the VA include withholding/ withdrawing life-sustaining treatments, palliative sedation, and voluntary stopping of eating and drinking.39 Given the complexities of MAID, the VHA should initiate discussions of MAID, educate clinicians on what they can and cannot do as federal employees, and establish committees to discuss approaches that could minimize pain for patients and clinician distress.
Conclusions
Caring for veterans who request MAID requires clinicians to navigate a complex intersection of ethical obligations, legal constraints, and patient preferences. Within the VHA, where MAID is prohibited, clinicians must balance respect for patient autonomy with adherence to VA regulations. Comprehensive assessment to identify sources of distress, interdisciplinary collaboration, and recognition of permissible alternatives that align with patients’ values are essential to provide effective end-of-life care at the VHA for individuals considering MAID. As requests for MAID continue to emerge in clinical practice, the VHA has an opportunity to strengthen clinician education, clarify institutional expectations, and promote supportive structures that reduce both patient suffering and clinician moral distress.
- Meisel A, Snyder L, Quill T; American College of Physicians-- American Society of Internal Medicine End-of-Life Care Consensus Panel. Seven legal barriers to end-of- life care: myths, realities, and grains of truth. JAMA. 2000;284:2495-2501. doi:10.1001/jama.284.19.2495
- Physician-Assisted Suicide. American Medical Association Code of Medical Ethics. 2025. Accessed May 6, 2026. https://code-medical-ethics.ama-assn.org/ethics-opinions /physician-assisted-suicide
- Youngner SJ, Thoman R. AGS survey actually supports engaged neutrality for physician-assisted death. J Am Geriatr Soc. 2020;68:2140-2141. doi:10.1111/jgs.16679
- Physician-Assisted Dying. American Academy of Hospice and Palliative Medicine. Updated 2007. Accessed May 6, 2026. https://aahpm.org/advocacy/where-we-stand/pad/
- Ganzini L, Goy ER, Dobscha SK. Why Oregon patients request assisted death: family members’ views. J Gen Intern Med. 2008;23:154-157. doi:10.1007/s11606-007-0476-x
- Pearlman RA, Hsu C, Starks H, et al. Motivations for physician-assisted suicide: patient and family voices. J Gen Intern Med. 2005;20:234-239. doi:10.1111/j.1525-1497.2005.40225.x
- Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113:941- 948. doi:10.7326/0003-4819-113-12-941
- Fässberg MM, Cheung G, Canetto SS, et al. A systematic review of physical illness, functional disability, and suicidal behaviour among older adults.
Aging Ment Health. 2016;20:166-194. doi:10.1080/13607863.2015.1083945 - Gürhan N, Bes¸er NG, Polat Ü, et al. Suicide risk and depression in individuals with chronic illness. Community Ment Health J. 2019;55:840-848. doi:10.1007/s10597-019-00388-7
- Kye SY, Park K. Suicidal ideation and suicidal attempts among adults with chronic diseases: a crosssectional study. Compr Psychiatry. 2017;73:160-167. doi:10.1016/j.comppsych.2016.12.001
- Patten SB. Long-term medical conditions and major depression in a Canadian population study at waves 1 and 2. J Affect Disord. 2001;63:35-41. doi:10.1016/s0165-0327(00)00186-5
- Van der Kooy K, van Hout H, Marwijk H, et al. Depression and the risk for cardiovascular diseases: systematic review and meta analysis. Int J Geriatr Psychiatry. 2007;22:613- 626. doi:10.1002/gps.1723
- Sporinova B, Manns B, Tonelli M, et al. Association of mental health disorders with health care utilization and costs among adults with chronic disease. JAMA Netw Open. 2019;2:e199910. doi:10.1001/jamanetworkopen.2019.9910
- Ahmedani BK, Peterson EL, Hu Y, et al. Major physical health conditions and risk of suicide. Am J Prev Med. 2017;53:308-315. doi:10.1016/j.amepre.2017.04.001
- Rogers ML, Joiner TE, Shahar G. Suicidality in chronic illness: an overview of cognitive-affective and interpersonal factors. J Clin Psychol Med Settings. 2021;28:137-148. doi:10.1007/s10880-020-09749-x
- Sisti D, Mann JJ, Oquendo MA. Toward a distinct mental disorder—suicidal behavior. JAMA Psychiatry. 2020;77:661-662. doi:10.1001/jamapsychiatry.2020.0111
- Kolva E, Hoffecker L, Cox-Martin E. Suicidal ideation in patients with cancer: a systematic review of prevalence, risk factors, intervention and assessment. Palliat Support Care. 2020;18:206-219. doi:10.1017/S1478951519000610
- Zaorsky NG, Zhang Y, Tuanquin L, et al. Suicide among cancer patients. Nat Commun. 2019;10:207. doi:10.1038/s41467-018-08170-1
- Heinrich M, Hofmann L, Baurecht H, et al. Suicide risk and mortality among patients with cancer. Nat Med. 2022;28:852-859. doi:10.1038/s41591-022-01745-y
- Yousaf U, Christensen ML, Engholm G, et al. Suicides among Danish cancer patients 1971-1999. Br J Cancer. 2005;92:995-1000. doi:10.1038/sj.bjc.6602424
- Misono S, Weiss NS, Fann JR, et al. Incidence of suicide in persons with cancer. J Clin Oncol. 2008;26:4731-4738. doi:10.1200/JCO.2007.13.8941
- Björkenstam C, Edberg A, Ayoubi S, et al. Are cancer patients at higher suicide risk than the general population?. Scand J Public Health. 2005;33:208-214. doi:10.1080/14034940410019226
- Kinslow CJ, Kumar P, Olfson M, et al. Prognosis and risk of suicide after cancer diagnosis. Cancer. 2024;130:588-596. doi:10.1002/cncr.35118
- Men VY, Emery CR, Yip PSF. Characteristics of cancer patients who died by suicide: a quantitative study of 15-year coronial records. Psychooncology. 2021;30:1051-1058. doi:10.1002/pon.5634
- Abdel-Rahman O. Socioeconomic predictors of suicide risk among cancer patients in the United States: a population- based study. Cancer Epidemiol. 2019;63:101601. doi:10.1016/j.canep.2019.101601
- O’Dwyer ST, Janssens A, Sansom A, et al. Suicidality in family caregivers of people with long-term illnesses and disabilities: a scoping review. Compr Psychiatry. 2021;110:152261. doi:10.1016/j.comppsych.2021.152261
- Senf B, Maiwurm P, Fettel J. Attitudes and opinions towards suicidality in professionals working with oncology patients: results from an online survey. Support Care Cancer. 2022;30:1775-1786. doi:10.1007/s00520-021-06590-2
- Berardelli I, Belvisi D, Nardella A, et al. Suicide in Parkinson’s disease: a systematic review. CNS Neurol Disord Drug Targets. 2019;18:466-477. doi:10.2174/1871527318666190703093345
- Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-626. doi:10.1001/archpsyc.56.7.617
- Chen YY, Yu S, Hu YH, et al. Risk of suicide among patients with Parkinson disease. JAMA Psychiatry. 2021;78:293-301. doi:10.1001/jamapsychiatry.2020.4001
- Lee T, Lee HB, Ahn MH, et al. Increased suicide risk and clinical correlates of suicide among patients with Parkinson’s disease. Parkinsonism Relat Disord. 2016;32:102- 107. doi:10.1016/j.parkreldis.2016.09.006
- Georges JJ, Onwuteaka-Philipsen BD, Muller MT, et al. Relatives’ perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands. Death Stud. 2007;31:1-15. doi:10.1080/07481180600985041
- Smith KA, Goy ER, Harvath TA, et al. Quality of death and dying in patients who request physician-assisted death. J Palliat Med. 2011;14:445-450. doi:10.1089/jpm.2010.0425
- Ganzini L, Goy ER, Dobscha SK, et al. Mental health outcomes of family members of Oregonians who request physician aid in dying. J Pain Symptom Manage. 2009;38:807-815. doi:10.1016/j.jpainsymman.2009.04.026
- Yi R. Most Americans favor legal euthanasia. Gallup. August 8, 2024. Accessed May 6, 2026. https://news.gallup .com/poll/648215/americans-favor-legal-euthanasia.aspx
- Dholakia SY, Bagheri A, Simpson A. Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis. BMJ Open. 2022;12:e058523. doi:10.1136/bmjopen-2021-058523
- Kozlov E, Luth EA, Nemeth S, et al. Knowl - edge of and preferences for medical aid in dying. JAMA Netw Open. 2025;8:e2461495. doi:10.1001/jamanetworkopen.2024.61495
- Geppert C; Veterans Administration National Center for Ethics in Health Care. Medical aid in dying in the VA. Presented at: VISN 1 Palliative Care Summit, September 2024.
- National Ethics Committee, Veterans Health Administration. The ethics of palliative sedation as a therapy of last resort. Am J Hosp Palliat Care. 2006;23:483-491. doi:10.1177/1049909106294883
Requests for medical aid in dying (MAID) within the Veterans Health Administration (VHA) present unique ethical, legal, and clinical challenges. MAID is a process in which a physician provides a terminally ill patient with the means to end their own life. It is expressly prohibited by federal law, including within the US Department of Veterans Affairs (VA), regardless of its legality at the state level.1 MAID is also prohibited within community care institutions funded by the VA. The American Medical Association, American Geriatrics Society, and American Academy of Hospice and Palliative Medicine have adopted neutral positions regarding MAID due to varying opinions among their respective members.2-4 VHA palliative care clinicians are trained to identify and honor preferences for care and alleviate physical and emotional distress, which may complicate the management of MAID requests. Veterans can request MAID due to their desire for autonomy and pain relief, but the VHA prohibits clinicians from honoring these specific preferences. The inability to help veterans achieve their care preferences conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.
This case report describes the management of a veteran who requested MAID while also exhibiting active suicidal ideation. The patient’s distress stemmed from fears of impending loss of autonomy and functional decline, factors frequently linked to requests for MAID in terminally ill patients.5,6 Addressing the veteran’s request for MAID required balancing respect for patient autonomy and concerns about future suffering with the VA mission to protect veterans from self-harm and provide mental health care for suicidal ideation. This case highlights the importance of nuanced clinical approaches, ethical reflection, and interdisciplinary collaboration in navigating such complex scenarios. Informed consent was obtained from the patient’s family and health care agent (HCA) to publish this report.
Case Presentation
A 73-year-old male veteran, with Parkinson disease (PD), diagnosed at age 52 years, was referred to palliative care following diagnosis of a glioblastoma multiforme (GBM). The patient also had a history of major depressive disorder (MDD), suicidal ideation (SI), benign prostatic hypertrophy, and migraines. He was divorced, had no children, and his only sibling (sister) was deceased. His brother-in-law served as his HCA.
The patient had many close friends in the community, was an architect by training, and was active in the removal of barriers and increasing access for people with disabilities. Since 2010, about 7 years before his PD diagnosis, the patient used psychiatry and psychology resources to treat MDD, functional decline, and SI. He was hospitalized in 2016 after self-administration of heroin. During the hospitalization the patient received a high risk for suicide label. He articulated a firm and long-standing belief in his right to die and shared plans to end his life when he experienced a significant decline in his independence and quality of life (QoL).
When diagnosed with PD, the patient shared that his QoL was of utmost importance. He was aware that he would have significant physical decline as PD progressed and felt like there would be a point when his QoL would not be acceptable. When that happened, he wanted to end his life by available means. He was followed closely by his VHA care team for physical and emotional distress.
When diagnosed with a GBM in 2023, the patient declined treatment and was referred to palliative care, which had sporadically treated him for PD-related distress prior to 2023. During his previous palliative care visits, the patient had discussed a desire to engage in MAID when his functional status declined. After the GBM diagnosis, he reported no acute intent to harm himself with heroin, but planned to travel to Vermont for MAID when he felt he no longer had an adequate QoL based on functional capability.
Pharmacologic and nonpharmacologic approaches were used to treat the patient’s pain. He reported significant benefit from biofeedback therapy provided by the VA Headache Center of Excellence. This work also reconnected him to meditation, which he used daily to relieve pain and distress. The patient managed head pain with nonpharmacologic and pharmacologic interventions for 6 months and reported satisfaction with his QoL.
After 6 months, imaging showed progression of the brain tumor, which was associated with more fatigue and memory decline. At that time, the patient was enrolled in home hospice and reported continued intent to pursue MAID in Vermont but had not taken steps toward carrying it out. The patient understood the VA could not assist him in pursuing MAID; however, his care team was able to assist him in sharing his preferences for care with his loved ones and health care power of attorney.
He experienced rapid functional and cognitive decline due to progression of the GBM and was admitted to the VA Connecticut Healthcare System (VACHS) acute care unit where he exhibited confusion and screened positive for delirium using the Confusion Assessment Method.7 His physical and cognitive deterioration was likely due to the progressive brain tumor, and the patient lacked the capacity to make complex medical decisions. Formal consent was obtained from his HCA to transfer him to inpatient hospice. Psychiatry followed the patient throughout.
After 4 weeks of hospice care, the patient had a witnessed suicide attempt while the nurse was assisting him in the bathroom. The patient attempted to use hospital pajamas to hang himself when he wrapped a hospital gown around his neck and stated he was trying to tie a knot. Due to his confusion and delirium, the patient was unable to express his reasoning for the suicide attempt. He was seen by the Psychiatry service, which determined that his suicide risk was low to intermediate. The Psychiatry service did not recommend a 1:1 safety sitter, but suggested medication changes. Levetiracetam was discontinued, and valproate 500 mg orally twice daily was initiated for seizure prevention.
The hospice team was informed of the suicide attempt and psychiatry recommendations. The suicide prevention team was also updated following this event and agreed with psychiatry recommendations. The patient continued to decline, was no longer able to get out of bed, and had minimal speech. The patient received comfort medications, including intravenous morphine 2 mg and lorazepam 0.5 mg as needed ≤ 4 times daily. He died 8 days later.
Discussion
Chronic medical illness has been associated with increased suicide risk.8-10 The increased risk of suicide in chronically ill patients has been described as having as a bidirectional relationship with MDD, with depression not only increasing the risk of chronic medical illness but new-onset chronic medical illness being associated with new onset depression.11,12 Chronic medical conditions are associated with numerous psychiatric disorders, and the presence of a comorbid psychiatric illness is associated with higher rates of hospitalization, emergency department visits, and increased health care costs.13 Research has found that the association between suicide risk and chronic medical illness remains even after accounting for comorbid mental health disorders.14 This has been postulated to be due to a multitude of interpersonal, behavioral, cognitive, and affective factors (eg, perceived burdensomeness, loneliness, stress, pain catastrophizing, self-criticism).15 Additionally, some researchers have questioned whether suicidality constitutes a distinct mental disorder.16
Patients with cancer are at increased risk for suicidal ideation (including passive death wishes) and suicide attempts.17,18 Recent data indicate that compared with the general population, there is an 85% increased risk of suicide mortality in patients with cancer.19 Studies show the incidence of suicide is greater for individuals with cancer compared with the general population, with standardized mortality ratios ranging from 1.4 to 5.7.20-22
Among patients with cancer, suicide risk is associated with several factors: worse prognosis, older age, male sex, living in a socioeconomically vulnerable environment, and increased communication about suicidal intent prior to death.23-25 Just as the prevalence of suicidal ideation in people with cancer varies widely, reported rates of suicidality in caregivers of patients with cancer range from 2.7% to 71%.17,26 A survey of health care workers indicated the following reasons patients with cancer may die by suicide or seek aid in assisted suicide: social isolation, pain, physical impairment, loss of autonomy and meaning, terminal illness, and psychic distress and desperation.27
As with cancer, patients with PD exhibit increased suicidal ideation compared with the general population.28,29 Two studies found the suicide rate in individuals with PD is about twice as high as it is in the general population.30,31 Among people with PD, male sex, younger age, initial onset of motor symptoms in the upper or both upper and lower extremities, history of depression or any psychiatric diagnosis, delusions, higher levodopa dosing, and urban residence have been clinically correlated with suicide. Jumping has been a frequent method of suicide.30,31
Some research has evaluated the perspectives of loved ones after a patient chooses MAID. A study in the Netherlands found that 92% of relatives surveyed believed that access to MAID improved QoL and reduced pain at the end of life.32 In another, family members of individuals who used MAID reported higher quality on items related to physical symptom control and preparedness for death, compared with individuals who did not pursue MAID or who requested but did not receive it. There were no differences on items assessing connectedness to their loved one, being unafraid of death, level of consciousness, or global quality of death items.33 Another study found no significant differences in depression rates, grief, or use of mental health services among Oregon families whose loved ones died using MAID compared with those who did not.34
The higher suicide rate among terminally ill patients highlights the complex issue of MAID and the right to die. It is important to differentiate between euthanasia and medically-assisted dying. Euthanasia is an act whereby a person other than the patient acts to cause death. In MAID, the patient is provided with a medication that they self-administer. Recent Gallup polls found that > 70% of Americans believe physicians should be “allowed by law to end the patient’s life by some painless means if the patient and his or her family request it.”35
It is important to acknowledge MAID in the context of chronic suicidality, like in the case described in this article. It is imperative not to dismiss reports of suicidality in this population. Ignoring reports of suicidal ideation may lead to decreased access to pharmacologic and nonpharmacologic interventions. It is also important to maintain a timeline of symptom occurrence and to differentiate between chronic suicidality and the desire to die associated with having a terminal illness. A thorough assessment is necessary to assess whether the patient’s decision stems from a calculated decision with preserved capacity or from underlying mental health conditions. Other factors that may lead the patient to a hastened death (ie, pain, poor psychosocial support, delirium, cognitive impairment, incomplete understanding of treatment/prognosis) need to be addressed prior to finalizing choices. In this case, an assessment was performed by psychiatry, psychology, social work, and chaplains to ensure comprehensive evaluation.
The VHA offers resources to assist individuals experiencing suicidal ideation, including suicide prevention coordinators who work directly with veterans and offer consultation to teams working with veterans at risk for suicide. Support for VHA clinicians who treat veterans considering MAID may help address any moral distress. In this case, the care team met early for overnight sign-out, had daily core hospice team meetings, as-needed safety huddles, and weekly care plan meetings to ensure maximal physical and emotional comfort for the patient. These meetings cultivate open, honest, and transparent discussions regarding any staff concerns or personal distress around the plan of care. The VACHS chief well-being officer was also available for all staff.
A systematic review of the impact of MAID on clinicians found that MAID legislation influenced emotional responses. For countries whose MAID legislation emphasized alleviation from pain in addition to terminal illness, clinicians reported more emotional reflection. Whereas, in countries where MAID legislation is stricter and can be applied solely for terminal illness, clinicians reported a stronger and more polarizing range of emotions.36 This highlights the potential influence of the context in which clinicians work on their emotional experience with MAID. Given that MAID is not permitted in the VA, staff members may experience heightened emotional responses. In a survey of US adults, there was an interest in using MAID but there were knowledge deficits regarding the process and legality.37
Legal aspects come into play as well with regards to MAID. Eligibility requires the patient be aged ≥ 18 years, be terminally ill with a prognosis of ≤ 6 months, have the capacity to make their own health care decision, and be able to self-administer the medication. States also may have residency restrictions. Special care and adequate education are needed, as having anyone but the patient administer the medication may be considered criminal. Furthermore, since MAID is not allowed federally, this creates further distress in VHA clinicians entrusted to minimizing pain for patients.
Strategies to support veterans given prohibition of MAID include: conversations about the patient’s values, clarifying reasons for request, assessing all domains of distress, affirming concerns with compassion and nonjudgment, addressing any pain using pharmacologic and nonpharmacologic interventions, providing education on other permissible options for end-of-life care, and consulting other specialties.38
End-of-life options permitted by the VA include withholding/ withdrawing life-sustaining treatments, palliative sedation, and voluntary stopping of eating and drinking.39 Given the complexities of MAID, the VHA should initiate discussions of MAID, educate clinicians on what they can and cannot do as federal employees, and establish committees to discuss approaches that could minimize pain for patients and clinician distress.
Conclusions
Caring for veterans who request MAID requires clinicians to navigate a complex intersection of ethical obligations, legal constraints, and patient preferences. Within the VHA, where MAID is prohibited, clinicians must balance respect for patient autonomy with adherence to VA regulations. Comprehensive assessment to identify sources of distress, interdisciplinary collaboration, and recognition of permissible alternatives that align with patients’ values are essential to provide effective end-of-life care at the VHA for individuals considering MAID. As requests for MAID continue to emerge in clinical practice, the VHA has an opportunity to strengthen clinician education, clarify institutional expectations, and promote supportive structures that reduce both patient suffering and clinician moral distress.
Requests for medical aid in dying (MAID) within the Veterans Health Administration (VHA) present unique ethical, legal, and clinical challenges. MAID is a process in which a physician provides a terminally ill patient with the means to end their own life. It is expressly prohibited by federal law, including within the US Department of Veterans Affairs (VA), regardless of its legality at the state level.1 MAID is also prohibited within community care institutions funded by the VA. The American Medical Association, American Geriatrics Society, and American Academy of Hospice and Palliative Medicine have adopted neutral positions regarding MAID due to varying opinions among their respective members.2-4 VHA palliative care clinicians are trained to identify and honor preferences for care and alleviate physical and emotional distress, which may complicate the management of MAID requests. Veterans can request MAID due to their desire for autonomy and pain relief, but the VHA prohibits clinicians from honoring these specific preferences. The inability to help veterans achieve their care preferences conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.
This case report describes the management of a veteran who requested MAID while also exhibiting active suicidal ideation. The patient’s distress stemmed from fears of impending loss of autonomy and functional decline, factors frequently linked to requests for MAID in terminally ill patients.5,6 Addressing the veteran’s request for MAID required balancing respect for patient autonomy and concerns about future suffering with the VA mission to protect veterans from self-harm and provide mental health care for suicidal ideation. This case highlights the importance of nuanced clinical approaches, ethical reflection, and interdisciplinary collaboration in navigating such complex scenarios. Informed consent was obtained from the patient’s family and health care agent (HCA) to publish this report.
Case Presentation
A 73-year-old male veteran, with Parkinson disease (PD), diagnosed at age 52 years, was referred to palliative care following diagnosis of a glioblastoma multiforme (GBM). The patient also had a history of major depressive disorder (MDD), suicidal ideation (SI), benign prostatic hypertrophy, and migraines. He was divorced, had no children, and his only sibling (sister) was deceased. His brother-in-law served as his HCA.
The patient had many close friends in the community, was an architect by training, and was active in the removal of barriers and increasing access for people with disabilities. Since 2010, about 7 years before his PD diagnosis, the patient used psychiatry and psychology resources to treat MDD, functional decline, and SI. He was hospitalized in 2016 after self-administration of heroin. During the hospitalization the patient received a high risk for suicide label. He articulated a firm and long-standing belief in his right to die and shared plans to end his life when he experienced a significant decline in his independence and quality of life (QoL).
When diagnosed with PD, the patient shared that his QoL was of utmost importance. He was aware that he would have significant physical decline as PD progressed and felt like there would be a point when his QoL would not be acceptable. When that happened, he wanted to end his life by available means. He was followed closely by his VHA care team for physical and emotional distress.
When diagnosed with a GBM in 2023, the patient declined treatment and was referred to palliative care, which had sporadically treated him for PD-related distress prior to 2023. During his previous palliative care visits, the patient had discussed a desire to engage in MAID when his functional status declined. After the GBM diagnosis, he reported no acute intent to harm himself with heroin, but planned to travel to Vermont for MAID when he felt he no longer had an adequate QoL based on functional capability.
Pharmacologic and nonpharmacologic approaches were used to treat the patient’s pain. He reported significant benefit from biofeedback therapy provided by the VA Headache Center of Excellence. This work also reconnected him to meditation, which he used daily to relieve pain and distress. The patient managed head pain with nonpharmacologic and pharmacologic interventions for 6 months and reported satisfaction with his QoL.
After 6 months, imaging showed progression of the brain tumor, which was associated with more fatigue and memory decline. At that time, the patient was enrolled in home hospice and reported continued intent to pursue MAID in Vermont but had not taken steps toward carrying it out. The patient understood the VA could not assist him in pursuing MAID; however, his care team was able to assist him in sharing his preferences for care with his loved ones and health care power of attorney.
He experienced rapid functional and cognitive decline due to progression of the GBM and was admitted to the VA Connecticut Healthcare System (VACHS) acute care unit where he exhibited confusion and screened positive for delirium using the Confusion Assessment Method.7 His physical and cognitive deterioration was likely due to the progressive brain tumor, and the patient lacked the capacity to make complex medical decisions. Formal consent was obtained from his HCA to transfer him to inpatient hospice. Psychiatry followed the patient throughout.
After 4 weeks of hospice care, the patient had a witnessed suicide attempt while the nurse was assisting him in the bathroom. The patient attempted to use hospital pajamas to hang himself when he wrapped a hospital gown around his neck and stated he was trying to tie a knot. Due to his confusion and delirium, the patient was unable to express his reasoning for the suicide attempt. He was seen by the Psychiatry service, which determined that his suicide risk was low to intermediate. The Psychiatry service did not recommend a 1:1 safety sitter, but suggested medication changes. Levetiracetam was discontinued, and valproate 500 mg orally twice daily was initiated for seizure prevention.
The hospice team was informed of the suicide attempt and psychiatry recommendations. The suicide prevention team was also updated following this event and agreed with psychiatry recommendations. The patient continued to decline, was no longer able to get out of bed, and had minimal speech. The patient received comfort medications, including intravenous morphine 2 mg and lorazepam 0.5 mg as needed ≤ 4 times daily. He died 8 days later.
Discussion
Chronic medical illness has been associated with increased suicide risk.8-10 The increased risk of suicide in chronically ill patients has been described as having as a bidirectional relationship with MDD, with depression not only increasing the risk of chronic medical illness but new-onset chronic medical illness being associated with new onset depression.11,12 Chronic medical conditions are associated with numerous psychiatric disorders, and the presence of a comorbid psychiatric illness is associated with higher rates of hospitalization, emergency department visits, and increased health care costs.13 Research has found that the association between suicide risk and chronic medical illness remains even after accounting for comorbid mental health disorders.14 This has been postulated to be due to a multitude of interpersonal, behavioral, cognitive, and affective factors (eg, perceived burdensomeness, loneliness, stress, pain catastrophizing, self-criticism).15 Additionally, some researchers have questioned whether suicidality constitutes a distinct mental disorder.16
Patients with cancer are at increased risk for suicidal ideation (including passive death wishes) and suicide attempts.17,18 Recent data indicate that compared with the general population, there is an 85% increased risk of suicide mortality in patients with cancer.19 Studies show the incidence of suicide is greater for individuals with cancer compared with the general population, with standardized mortality ratios ranging from 1.4 to 5.7.20-22
Among patients with cancer, suicide risk is associated with several factors: worse prognosis, older age, male sex, living in a socioeconomically vulnerable environment, and increased communication about suicidal intent prior to death.23-25 Just as the prevalence of suicidal ideation in people with cancer varies widely, reported rates of suicidality in caregivers of patients with cancer range from 2.7% to 71%.17,26 A survey of health care workers indicated the following reasons patients with cancer may die by suicide or seek aid in assisted suicide: social isolation, pain, physical impairment, loss of autonomy and meaning, terminal illness, and psychic distress and desperation.27
As with cancer, patients with PD exhibit increased suicidal ideation compared with the general population.28,29 Two studies found the suicide rate in individuals with PD is about twice as high as it is in the general population.30,31 Among people with PD, male sex, younger age, initial onset of motor symptoms in the upper or both upper and lower extremities, history of depression or any psychiatric diagnosis, delusions, higher levodopa dosing, and urban residence have been clinically correlated with suicide. Jumping has been a frequent method of suicide.30,31
Some research has evaluated the perspectives of loved ones after a patient chooses MAID. A study in the Netherlands found that 92% of relatives surveyed believed that access to MAID improved QoL and reduced pain at the end of life.32 In another, family members of individuals who used MAID reported higher quality on items related to physical symptom control and preparedness for death, compared with individuals who did not pursue MAID or who requested but did not receive it. There were no differences on items assessing connectedness to their loved one, being unafraid of death, level of consciousness, or global quality of death items.33 Another study found no significant differences in depression rates, grief, or use of mental health services among Oregon families whose loved ones died using MAID compared with those who did not.34
The higher suicide rate among terminally ill patients highlights the complex issue of MAID and the right to die. It is important to differentiate between euthanasia and medically-assisted dying. Euthanasia is an act whereby a person other than the patient acts to cause death. In MAID, the patient is provided with a medication that they self-administer. Recent Gallup polls found that > 70% of Americans believe physicians should be “allowed by law to end the patient’s life by some painless means if the patient and his or her family request it.”35
It is important to acknowledge MAID in the context of chronic suicidality, like in the case described in this article. It is imperative not to dismiss reports of suicidality in this population. Ignoring reports of suicidal ideation may lead to decreased access to pharmacologic and nonpharmacologic interventions. It is also important to maintain a timeline of symptom occurrence and to differentiate between chronic suicidality and the desire to die associated with having a terminal illness. A thorough assessment is necessary to assess whether the patient’s decision stems from a calculated decision with preserved capacity or from underlying mental health conditions. Other factors that may lead the patient to a hastened death (ie, pain, poor psychosocial support, delirium, cognitive impairment, incomplete understanding of treatment/prognosis) need to be addressed prior to finalizing choices. In this case, an assessment was performed by psychiatry, psychology, social work, and chaplains to ensure comprehensive evaluation.
The VHA offers resources to assist individuals experiencing suicidal ideation, including suicide prevention coordinators who work directly with veterans and offer consultation to teams working with veterans at risk for suicide. Support for VHA clinicians who treat veterans considering MAID may help address any moral distress. In this case, the care team met early for overnight sign-out, had daily core hospice team meetings, as-needed safety huddles, and weekly care plan meetings to ensure maximal physical and emotional comfort for the patient. These meetings cultivate open, honest, and transparent discussions regarding any staff concerns or personal distress around the plan of care. The VACHS chief well-being officer was also available for all staff.
A systematic review of the impact of MAID on clinicians found that MAID legislation influenced emotional responses. For countries whose MAID legislation emphasized alleviation from pain in addition to terminal illness, clinicians reported more emotional reflection. Whereas, in countries where MAID legislation is stricter and can be applied solely for terminal illness, clinicians reported a stronger and more polarizing range of emotions.36 This highlights the potential influence of the context in which clinicians work on their emotional experience with MAID. Given that MAID is not permitted in the VA, staff members may experience heightened emotional responses. In a survey of US adults, there was an interest in using MAID but there were knowledge deficits regarding the process and legality.37
Legal aspects come into play as well with regards to MAID. Eligibility requires the patient be aged ≥ 18 years, be terminally ill with a prognosis of ≤ 6 months, have the capacity to make their own health care decision, and be able to self-administer the medication. States also may have residency restrictions. Special care and adequate education are needed, as having anyone but the patient administer the medication may be considered criminal. Furthermore, since MAID is not allowed federally, this creates further distress in VHA clinicians entrusted to minimizing pain for patients.
Strategies to support veterans given prohibition of MAID include: conversations about the patient’s values, clarifying reasons for request, assessing all domains of distress, affirming concerns with compassion and nonjudgment, addressing any pain using pharmacologic and nonpharmacologic interventions, providing education on other permissible options for end-of-life care, and consulting other specialties.38
End-of-life options permitted by the VA include withholding/ withdrawing life-sustaining treatments, palliative sedation, and voluntary stopping of eating and drinking.39 Given the complexities of MAID, the VHA should initiate discussions of MAID, educate clinicians on what they can and cannot do as federal employees, and establish committees to discuss approaches that could minimize pain for patients and clinician distress.
Conclusions
Caring for veterans who request MAID requires clinicians to navigate a complex intersection of ethical obligations, legal constraints, and patient preferences. Within the VHA, where MAID is prohibited, clinicians must balance respect for patient autonomy with adherence to VA regulations. Comprehensive assessment to identify sources of distress, interdisciplinary collaboration, and recognition of permissible alternatives that align with patients’ values are essential to provide effective end-of-life care at the VHA for individuals considering MAID. As requests for MAID continue to emerge in clinical practice, the VHA has an opportunity to strengthen clinician education, clarify institutional expectations, and promote supportive structures that reduce both patient suffering and clinician moral distress.
- Meisel A, Snyder L, Quill T; American College of Physicians-- American Society of Internal Medicine End-of-Life Care Consensus Panel. Seven legal barriers to end-of- life care: myths, realities, and grains of truth. JAMA. 2000;284:2495-2501. doi:10.1001/jama.284.19.2495
- Physician-Assisted Suicide. American Medical Association Code of Medical Ethics. 2025. Accessed May 6, 2026. https://code-medical-ethics.ama-assn.org/ethics-opinions /physician-assisted-suicide
- Youngner SJ, Thoman R. AGS survey actually supports engaged neutrality for physician-assisted death. J Am Geriatr Soc. 2020;68:2140-2141. doi:10.1111/jgs.16679
- Physician-Assisted Dying. American Academy of Hospice and Palliative Medicine. Updated 2007. Accessed May 6, 2026. https://aahpm.org/advocacy/where-we-stand/pad/
- Ganzini L, Goy ER, Dobscha SK. Why Oregon patients request assisted death: family members’ views. J Gen Intern Med. 2008;23:154-157. doi:10.1007/s11606-007-0476-x
- Pearlman RA, Hsu C, Starks H, et al. Motivations for physician-assisted suicide: patient and family voices. J Gen Intern Med. 2005;20:234-239. doi:10.1111/j.1525-1497.2005.40225.x
- Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113:941- 948. doi:10.7326/0003-4819-113-12-941
- Fässberg MM, Cheung G, Canetto SS, et al. A systematic review of physical illness, functional disability, and suicidal behaviour among older adults.
Aging Ment Health. 2016;20:166-194. doi:10.1080/13607863.2015.1083945 - Gürhan N, Bes¸er NG, Polat Ü, et al. Suicide risk and depression in individuals with chronic illness. Community Ment Health J. 2019;55:840-848. doi:10.1007/s10597-019-00388-7
- Kye SY, Park K. Suicidal ideation and suicidal attempts among adults with chronic diseases: a crosssectional study. Compr Psychiatry. 2017;73:160-167. doi:10.1016/j.comppsych.2016.12.001
- Patten SB. Long-term medical conditions and major depression in a Canadian population study at waves 1 and 2. J Affect Disord. 2001;63:35-41. doi:10.1016/s0165-0327(00)00186-5
- Van der Kooy K, van Hout H, Marwijk H, et al. Depression and the risk for cardiovascular diseases: systematic review and meta analysis. Int J Geriatr Psychiatry. 2007;22:613- 626. doi:10.1002/gps.1723
- Sporinova B, Manns B, Tonelli M, et al. Association of mental health disorders with health care utilization and costs among adults with chronic disease. JAMA Netw Open. 2019;2:e199910. doi:10.1001/jamanetworkopen.2019.9910
- Ahmedani BK, Peterson EL, Hu Y, et al. Major physical health conditions and risk of suicide. Am J Prev Med. 2017;53:308-315. doi:10.1016/j.amepre.2017.04.001
- Rogers ML, Joiner TE, Shahar G. Suicidality in chronic illness: an overview of cognitive-affective and interpersonal factors. J Clin Psychol Med Settings. 2021;28:137-148. doi:10.1007/s10880-020-09749-x
- Sisti D, Mann JJ, Oquendo MA. Toward a distinct mental disorder—suicidal behavior. JAMA Psychiatry. 2020;77:661-662. doi:10.1001/jamapsychiatry.2020.0111
- Kolva E, Hoffecker L, Cox-Martin E. Suicidal ideation in patients with cancer: a systematic review of prevalence, risk factors, intervention and assessment. Palliat Support Care. 2020;18:206-219. doi:10.1017/S1478951519000610
- Zaorsky NG, Zhang Y, Tuanquin L, et al. Suicide among cancer patients. Nat Commun. 2019;10:207. doi:10.1038/s41467-018-08170-1
- Heinrich M, Hofmann L, Baurecht H, et al. Suicide risk and mortality among patients with cancer. Nat Med. 2022;28:852-859. doi:10.1038/s41591-022-01745-y
- Yousaf U, Christensen ML, Engholm G, et al. Suicides among Danish cancer patients 1971-1999. Br J Cancer. 2005;92:995-1000. doi:10.1038/sj.bjc.6602424
- Misono S, Weiss NS, Fann JR, et al. Incidence of suicide in persons with cancer. J Clin Oncol. 2008;26:4731-4738. doi:10.1200/JCO.2007.13.8941
- Björkenstam C, Edberg A, Ayoubi S, et al. Are cancer patients at higher suicide risk than the general population?. Scand J Public Health. 2005;33:208-214. doi:10.1080/14034940410019226
- Kinslow CJ, Kumar P, Olfson M, et al. Prognosis and risk of suicide after cancer diagnosis. Cancer. 2024;130:588-596. doi:10.1002/cncr.35118
- Men VY, Emery CR, Yip PSF. Characteristics of cancer patients who died by suicide: a quantitative study of 15-year coronial records. Psychooncology. 2021;30:1051-1058. doi:10.1002/pon.5634
- Abdel-Rahman O. Socioeconomic predictors of suicide risk among cancer patients in the United States: a population- based study. Cancer Epidemiol. 2019;63:101601. doi:10.1016/j.canep.2019.101601
- O’Dwyer ST, Janssens A, Sansom A, et al. Suicidality in family caregivers of people with long-term illnesses and disabilities: a scoping review. Compr Psychiatry. 2021;110:152261. doi:10.1016/j.comppsych.2021.152261
- Senf B, Maiwurm P, Fettel J. Attitudes and opinions towards suicidality in professionals working with oncology patients: results from an online survey. Support Care Cancer. 2022;30:1775-1786. doi:10.1007/s00520-021-06590-2
- Berardelli I, Belvisi D, Nardella A, et al. Suicide in Parkinson’s disease: a systematic review. CNS Neurol Disord Drug Targets. 2019;18:466-477. doi:10.2174/1871527318666190703093345
- Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-626. doi:10.1001/archpsyc.56.7.617
- Chen YY, Yu S, Hu YH, et al. Risk of suicide among patients with Parkinson disease. JAMA Psychiatry. 2021;78:293-301. doi:10.1001/jamapsychiatry.2020.4001
- Lee T, Lee HB, Ahn MH, et al. Increased suicide risk and clinical correlates of suicide among patients with Parkinson’s disease. Parkinsonism Relat Disord. 2016;32:102- 107. doi:10.1016/j.parkreldis.2016.09.006
- Georges JJ, Onwuteaka-Philipsen BD, Muller MT, et al. Relatives’ perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands. Death Stud. 2007;31:1-15. doi:10.1080/07481180600985041
- Smith KA, Goy ER, Harvath TA, et al. Quality of death and dying in patients who request physician-assisted death. J Palliat Med. 2011;14:445-450. doi:10.1089/jpm.2010.0425
- Ganzini L, Goy ER, Dobscha SK, et al. Mental health outcomes of family members of Oregonians who request physician aid in dying. J Pain Symptom Manage. 2009;38:807-815. doi:10.1016/j.jpainsymman.2009.04.026
- Yi R. Most Americans favor legal euthanasia. Gallup. August 8, 2024. Accessed May 6, 2026. https://news.gallup .com/poll/648215/americans-favor-legal-euthanasia.aspx
- Dholakia SY, Bagheri A, Simpson A. Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis. BMJ Open. 2022;12:e058523. doi:10.1136/bmjopen-2021-058523
- Kozlov E, Luth EA, Nemeth S, et al. Knowl - edge of and preferences for medical aid in dying. JAMA Netw Open. 2025;8:e2461495. doi:10.1001/jamanetworkopen.2024.61495
- Geppert C; Veterans Administration National Center for Ethics in Health Care. Medical aid in dying in the VA. Presented at: VISN 1 Palliative Care Summit, September 2024.
- National Ethics Committee, Veterans Health Administration. The ethics of palliative sedation as a therapy of last resort. Am J Hosp Palliat Care. 2006;23:483-491. doi:10.1177/1049909106294883
- Meisel A, Snyder L, Quill T; American College of Physicians-- American Society of Internal Medicine End-of-Life Care Consensus Panel. Seven legal barriers to end-of- life care: myths, realities, and grains of truth. JAMA. 2000;284:2495-2501. doi:10.1001/jama.284.19.2495
- Physician-Assisted Suicide. American Medical Association Code of Medical Ethics. 2025. Accessed May 6, 2026. https://code-medical-ethics.ama-assn.org/ethics-opinions /physician-assisted-suicide
- Youngner SJ, Thoman R. AGS survey actually supports engaged neutrality for physician-assisted death. J Am Geriatr Soc. 2020;68:2140-2141. doi:10.1111/jgs.16679
- Physician-Assisted Dying. American Academy of Hospice and Palliative Medicine. Updated 2007. Accessed May 6, 2026. https://aahpm.org/advocacy/where-we-stand/pad/
- Ganzini L, Goy ER, Dobscha SK. Why Oregon patients request assisted death: family members’ views. J Gen Intern Med. 2008;23:154-157. doi:10.1007/s11606-007-0476-x
- Pearlman RA, Hsu C, Starks H, et al. Motivations for physician-assisted suicide: patient and family voices. J Gen Intern Med. 2005;20:234-239. doi:10.1111/j.1525-1497.2005.40225.x
- Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113:941- 948. doi:10.7326/0003-4819-113-12-941
- Fässberg MM, Cheung G, Canetto SS, et al. A systematic review of physical illness, functional disability, and suicidal behaviour among older adults.
Aging Ment Health. 2016;20:166-194. doi:10.1080/13607863.2015.1083945 - Gürhan N, Bes¸er NG, Polat Ü, et al. Suicide risk and depression in individuals with chronic illness. Community Ment Health J. 2019;55:840-848. doi:10.1007/s10597-019-00388-7
- Kye SY, Park K. Suicidal ideation and suicidal attempts among adults with chronic diseases: a crosssectional study. Compr Psychiatry. 2017;73:160-167. doi:10.1016/j.comppsych.2016.12.001
- Patten SB. Long-term medical conditions and major depression in a Canadian population study at waves 1 and 2. J Affect Disord. 2001;63:35-41. doi:10.1016/s0165-0327(00)00186-5
- Van der Kooy K, van Hout H, Marwijk H, et al. Depression and the risk for cardiovascular diseases: systematic review and meta analysis. Int J Geriatr Psychiatry. 2007;22:613- 626. doi:10.1002/gps.1723
- Sporinova B, Manns B, Tonelli M, et al. Association of mental health disorders with health care utilization and costs among adults with chronic disease. JAMA Netw Open. 2019;2:e199910. doi:10.1001/jamanetworkopen.2019.9910
- Ahmedani BK, Peterson EL, Hu Y, et al. Major physical health conditions and risk of suicide. Am J Prev Med. 2017;53:308-315. doi:10.1016/j.amepre.2017.04.001
- Rogers ML, Joiner TE, Shahar G. Suicidality in chronic illness: an overview of cognitive-affective and interpersonal factors. J Clin Psychol Med Settings. 2021;28:137-148. doi:10.1007/s10880-020-09749-x
- Sisti D, Mann JJ, Oquendo MA. Toward a distinct mental disorder—suicidal behavior. JAMA Psychiatry. 2020;77:661-662. doi:10.1001/jamapsychiatry.2020.0111
- Kolva E, Hoffecker L, Cox-Martin E. Suicidal ideation in patients with cancer: a systematic review of prevalence, risk factors, intervention and assessment. Palliat Support Care. 2020;18:206-219. doi:10.1017/S1478951519000610
- Zaorsky NG, Zhang Y, Tuanquin L, et al. Suicide among cancer patients. Nat Commun. 2019;10:207. doi:10.1038/s41467-018-08170-1
- Heinrich M, Hofmann L, Baurecht H, et al. Suicide risk and mortality among patients with cancer. Nat Med. 2022;28:852-859. doi:10.1038/s41591-022-01745-y
- Yousaf U, Christensen ML, Engholm G, et al. Suicides among Danish cancer patients 1971-1999. Br J Cancer. 2005;92:995-1000. doi:10.1038/sj.bjc.6602424
- Misono S, Weiss NS, Fann JR, et al. Incidence of suicide in persons with cancer. J Clin Oncol. 2008;26:4731-4738. doi:10.1200/JCO.2007.13.8941
- Björkenstam C, Edberg A, Ayoubi S, et al. Are cancer patients at higher suicide risk than the general population?. Scand J Public Health. 2005;33:208-214. doi:10.1080/14034940410019226
- Kinslow CJ, Kumar P, Olfson M, et al. Prognosis and risk of suicide after cancer diagnosis. Cancer. 2024;130:588-596. doi:10.1002/cncr.35118
- Men VY, Emery CR, Yip PSF. Characteristics of cancer patients who died by suicide: a quantitative study of 15-year coronial records. Psychooncology. 2021;30:1051-1058. doi:10.1002/pon.5634
- Abdel-Rahman O. Socioeconomic predictors of suicide risk among cancer patients in the United States: a population- based study. Cancer Epidemiol. 2019;63:101601. doi:10.1016/j.canep.2019.101601
- O’Dwyer ST, Janssens A, Sansom A, et al. Suicidality in family caregivers of people with long-term illnesses and disabilities: a scoping review. Compr Psychiatry. 2021;110:152261. doi:10.1016/j.comppsych.2021.152261
- Senf B, Maiwurm P, Fettel J. Attitudes and opinions towards suicidality in professionals working with oncology patients: results from an online survey. Support Care Cancer. 2022;30:1775-1786. doi:10.1007/s00520-021-06590-2
- Berardelli I, Belvisi D, Nardella A, et al. Suicide in Parkinson’s disease: a systematic review. CNS Neurol Disord Drug Targets. 2019;18:466-477. doi:10.2174/1871527318666190703093345
- Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-626. doi:10.1001/archpsyc.56.7.617
- Chen YY, Yu S, Hu YH, et al. Risk of suicide among patients with Parkinson disease. JAMA Psychiatry. 2021;78:293-301. doi:10.1001/jamapsychiatry.2020.4001
- Lee T, Lee HB, Ahn MH, et al. Increased suicide risk and clinical correlates of suicide among patients with Parkinson’s disease. Parkinsonism Relat Disord. 2016;32:102- 107. doi:10.1016/j.parkreldis.2016.09.006
- Georges JJ, Onwuteaka-Philipsen BD, Muller MT, et al. Relatives’ perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands. Death Stud. 2007;31:1-15. doi:10.1080/07481180600985041
- Smith KA, Goy ER, Harvath TA, et al. Quality of death and dying in patients who request physician-assisted death. J Palliat Med. 2011;14:445-450. doi:10.1089/jpm.2010.0425
- Ganzini L, Goy ER, Dobscha SK, et al. Mental health outcomes of family members of Oregonians who request physician aid in dying. J Pain Symptom Manage. 2009;38:807-815. doi:10.1016/j.jpainsymman.2009.04.026
- Yi R. Most Americans favor legal euthanasia. Gallup. August 8, 2024. Accessed May 6, 2026. https://news.gallup .com/poll/648215/americans-favor-legal-euthanasia.aspx
- Dholakia SY, Bagheri A, Simpson A. Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis. BMJ Open. 2022;12:e058523. doi:10.1136/bmjopen-2021-058523
- Kozlov E, Luth EA, Nemeth S, et al. Knowl - edge of and preferences for medical aid in dying. JAMA Netw Open. 2025;8:e2461495. doi:10.1001/jamanetworkopen.2024.61495
- Geppert C; Veterans Administration National Center for Ethics in Health Care. Medical aid in dying in the VA. Presented at: VISN 1 Palliative Care Summit, September 2024.
- National Ethics Committee, Veterans Health Administration. The ethics of palliative sedation as a therapy of last resort. Am J Hosp Palliat Care. 2006;23:483-491. doi:10.1177/1049909106294883
Managing Requests for Medical Aid in Dying Within the Veterans Health Administration
Managing Requests for Medical Aid in Dying Within the Veterans Health Administration
Who Gets to Determine Whether Home Is “Unsafe” at the End of Life?
Sometimes a patient at the end of life (EOL) just wants to go home. We recently treated such a patient, “Joe,” a 66-year-old veteran with end-stage chronic obstructive pulmonary disorder (COPD), severe hearing loss, and heavy alcohol use. A neighbor brought Joe to the hospital when he developed a urinary tract infection. Before hospitalization, Joe spent his days in bed. His neighbor was his designated health care agent (HCA) and caregiver, dropping off meals and bringing Joe to medical appointments. Joe had no other social support. In the hospital, Joe could not participate in physical therapy (PT) evaluations due to severe dyspnea on exertion. He was recommended for home PT, a home health aide, and home nursing, but Joe declined these services out of concern for encroachment on his independence. Given his heavy alcohol use, limited support, and functional limitations, the hospitalist team felt that Joe would be best served in a skilled nursing facility. As the palliative care team, we were consulted and felt that he was eligible for hospice. Joe simply wanted to go home.
Many patients like Joe experience functional decline at EOL, leading to increased care needs and transitions between sites of care.1 Some hospitalized patients at EOL want to transition directly to home, but due to their limited functioning and social support, discharge home may be deemed unsafe by health care professionals (HCPs). Clinicians then face the difficult balancing act of honoring patient wishes and avoiding a bad outcome. For patients at EOL, issues of capacity and risk become particularly salient. Furthermore, the unique structure of the US Department of Veterans Affairs (VA) health system and the psychosocial needs of some veterans add additional considerations for complex EOL discharges.2
End-of-life Decision Making
While patients may express strong preferences regarding their health care, their decision-making ability may worsen as they approach EOL. Contributing factors include older age, effects of hospitalization, treatment adverse effects, and comorbidities, including cognitive impairment. Studies of terminally ill patients show high rates of impaired decisional capacity.3,4 It is critical to assess capacity as part of discharge planning. Even when patients have the capacity, families and caregivers have an important voice, since they are often instrumental in maintaining patients at home.
Defining Risk
Determining whether a discharge is risky or unsafe is highly subjective, with differing opinions among clinicians and between patients and clinicians.5-7 In a qualitative study by Coombs and colleagues, HCPs tended toward a risk-averse approach to discharge decisions, sometimes favoring discharge to care facilities despite patient preferences.6 This approach also reflects pressures from the health care system to decrease the length of stay and reduce readmissions, important metrics for patient care and cost containment. However, keeping patients hospitalized or in nursing facilities does not completely mitigate risks (eg, falls) and carries other hazards (eg, nosocomial infections), as highlighted during the COVID-19 pandemic.7,8 The prospect of malpractice lawsuits and HCP moral distress about perceived risky home situations can also understandably affect decision making.
At the same time, risk calculation changes depending on the patient’s clinical status and priorities. Coombs and colleagues found that in contrast to clinicians, patients nearing EOL are willing to accept increasing risks and suboptimal living conditions to remain at home.6 What may be intolerable for a younger, healthier patient with a long life expectancy may be acceptable for someone who is approaching EOL. In our framework, a risky home discharge at EOL is considered one in which other adverse events, such as falls or inadequate symptom management, are likely.
Ethical Considerations
Unsafe discharges are challenging in part because some of the pillars of medical ethics can conflict. Prior articles have analyzed the ethical concerns of unsafe discharges in detail.9-11 Briefly, when patients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well. The concept of dignity of risk highlights the imperative to respect others’ decisions even when they increase the chance of harm, particularly given the overall shift in medicine from paternalism to shared decision making.12 Accommodating patient choice in how and where health care is received allows patients to regain some control over their lives, thereby enhancing their quality of life and promoting patient dignity, especially in their remaining days.13
Discharge Risk Framework
Our risk assessment framework helps clinicians more objectively identify factors that increase or decrease risk, inform discharge planning, partner with patients and families, give patients a prominent role in EOL decisions, and mitigate the risk of a bad outcome. This concept has been used in psychiatry, in which formal suicide assessment includes identifying risk factors and protective factors to estimate suicide risk and determine interventions.14 Similar to suicide risk estimation, this framework is based on clinical judgment rather than a specific calculation.
While this framework serves as a guide for determining and mitigating risk, we encourage teams to consider legal or ethical consultations in challenging cases, such as those in which patients lack both capacity and an involved HCA.
Step 1: Determine the patient’s capacity regarding disposition planning. Patients at EOL are at a higher risk of impaired decision-making capabilities; therefore, capacity evaluation is a critical step.
Step 2: Identify risk factors and protective factors for discharge home. Risk factors are intrinsic and extrinsic factors that increase risk such as functional or sensory impairments. Protective factors are intrinsic and extrinsic factors that decrease risk, including a good understanding of illness and consistent connection with the health care system (Table 1).
Step 3: Determine discharge to home risk level based on identified risk factors and protective factors. Patients may be at low, moderate, or high risk of having an adverse event, such as a fall or inadequate symptom control (Table 2).
Step 4: Identify risk mitigation strategies. These should be tailored to the patient based on the factors identified in Step 2. Examples include home nursing and therapy, mental health treatment, a medical alert system, and frequent contact between the patient and health care team.
Step 5: Meet with inpatient and outpatient HCP teams. Meetings should include the primary care professional (PCP) or relevant subspecialist, such as an oncologist for patients with cancer. For veterans receiving care solely at a local VA medical center, this can be easier to facilitate, but for veterans who receive care through both VA and non-VA systems, this step may require additional coordination. We also recommend including interdisciplinary team members, such as social workers, case managers, and the relevant home care or hospice agency. Certain agencies may decline admission if they perceive increased risk, such as no 24-hour care, perceived self-neglect, and limited instrumental support. During this meeting, HCPs discuss risk mitigation strategies identified in Step 4 and create a plan to propose to patients and families.
Step 6: Meet with patient, HCA, and family members. In addition to sharing information about prognosis, assessing caregiver capabilities and burden can guide conversations about discharge. The discharge plan should be determined through shared decision making.11 If the patient lacks capacity regarding disposition planning, this should be shared with the HCA. However, even when patients lack capacity, it is important to continue to engage them to understand their goals and preferences.
Step 7: Maximize risk mitigation strategies. If a moderate- or high-risk discharge is requested, the health care team should maximize risk mitigation strategies. For low-risk discharges, risk mitigation strategies can still promote safety, especially since risk increases as patients progress toward EOL. In some instances, patients, their HCAs, or caregivers may decline all risk mitigation strategies despite best efforts to communicate and negotiate options. In such circumstances, we recommend discussing the case with the outpatient team for a warm handoff. HCPs should also document all efforts (helpful from a legal standpoint as well as for the patient’s future treatment teams) and respect the decision to discharge home.
Applying the Framework
Our patient Joe provides a good illustration of how to implement this EOL framework. He was deemed to have the capacity to make decisions regarding discharge (Step 1). We determined his risk factors and protective factors for discharge (Step 2). His poor functional status, limited instrumental support, heavy alcohol use, rejection of home services, and communication barriers due to severe hearing impairment all increased his risk. Protective factors included an appreciation of functional limitations, intact cognition, and an involved HCA. Based on his limited instrumental support and poor function but good insight into limitations, discharge home was deemed to be of moderate risk (Step 3). Although risk factors such as alcohol use and severe hearing impairment could have raised his level to high risk, we felt that his involved HCA maintained him in the moderate-risk category.
We worked with the hospitalist team, PT, and audiology to identify multiple risk mitigation strategies: frequent phone calls between the HCA and outpatient palliative care team, home PT to improve transfers from bed to bedside commode, home nursing services either through a routine agency or hospice, and hearing aids for better communication (Steps 4 and 5). We then proposed these strategies to Joe and his HCA (Step 6). Due to concerns about infringement on his independence, Joe declined all home services but agreed to twice-daily check-ins by his HCA, frequent communication between his HCA and our team, and new hearing aids.
Joe returned home with the agreed-upon risk mitigation strategies in place (Step 7). Despite clinicians’ original reservations about sending Joe home without formal services, his HCA maintained close contact with our team, noting that Joe remained stable and happy to be at home in the months following discharge.
Conclusions
Fortunately, VA HCPs operate in an integrated health care system with access to psychological, social, and at-home medical support that can help mitigate risks. Still, we have benefitted from having a tool to help us evaluate risk systematically. Even if patients, families, and HCPs disagree on ideal discharge plans, this tool helps clinicians approach discharges methodically while maintaining open communication and partnership with patients. In doing so, our framework reflects the shift in medical culture from a patriarchal approach to shared decision-making practices regarding all aspects of medical care. Furthermore, we hope that this can help reduce clinician moral distress stemming from these challenging cases.
Future research on best practices for discharge risk assessment and optimizing home safety are needed. We also hope to evaluate the impact and effectiveness of our framework through interviews with key stakeholders. For Joe and other veterans like him, where to spend their final days may be the last important decision they make in life, and our framework allows for their voices to be better heard throughout the decision-making process.
Acknowledgments
We thank Brooke Lifland, MD, for her theoretical contributions to the concept behind this paper.
1. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
2. Casarett D, Pickard A, Amos Bailey F, et al. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage. 2008;35(2):115-125. doi:10.1016/j.jpainsymman.2007.03.008
3. Kolva E, Rosenfeld B, Brescia R, Comfort C. Assessing decision-making capacity at end of life. Gen Hosp Psychiatry. 2014;36(4):392-397. doi:10.1016/j.genhosppsych.2014.02.013
4. Kolva E, Rosenfeld B, Saracino R. Assessing the decision-making capacity of terminally ill patients with cancer. Am J Geriatr Psychiatry. 2018;26(5):523-531. doi:10.1016/j.jagp.2017.11.012
5. Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nurs. 1994;19(2):249-256. doi:10.1111/j.1365-2648.1994.tb01078.x
6. Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making. Palliat Med. 2017;31(7):617-624. doi:10.1177/0269216316673476
7. Hyslop B. ‘Not safe for discharge’? Words, values, and person-centred care. Age Ageing. 2020;49(3):334-336. doi:10.1093/ageing/afz170
8. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emerg Med J. 2006;23(10):753-755. doi:10.1136/emj.2006.037903
9. Swidler RN, Seastrum T, Shelton W. Difficult hospital inpatient discharge decisions: ethical, legal and clinical practice issues. Am J Bioeth. 2007;7(3):23-28. doi:10.1080/15265160601171739
10. Hill J, Filer W. Safety and ethical considerations in discharging patients to suboptimal living situations. AMA J Ethics. 2015;17(6):506-510. Published 2015 Jun 1. doi:10.1001/journalofethics.2015.17.6.ecas2-1506
11. West JC. What is an ethically informed approach to managing patient safety risk during discharge planning?. AMA J Ethics. 2020;22(11):E919-E923. Published 2020 Nov 1. doi:10.1001/amajethics.2020.919
12. Mukherjee D. Discharge decisions and the dignity of risk. Hastings Cent Rep. 2015;45(3):7-8. doi:10.1002/hast.441
13. Wheatley VJ, Baker JI. “Please, I want to go home”: ethical issues raised when considering choice of place of care in palliative care. Postgrad Med J. 2007;83(984):643-648. doi:10.1136/pgmj.2007.058487
14. Work Group on Suicidal Behaviors. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
Sometimes a patient at the end of life (EOL) just wants to go home. We recently treated such a patient, “Joe,” a 66-year-old veteran with end-stage chronic obstructive pulmonary disorder (COPD), severe hearing loss, and heavy alcohol use. A neighbor brought Joe to the hospital when he developed a urinary tract infection. Before hospitalization, Joe spent his days in bed. His neighbor was his designated health care agent (HCA) and caregiver, dropping off meals and bringing Joe to medical appointments. Joe had no other social support. In the hospital, Joe could not participate in physical therapy (PT) evaluations due to severe dyspnea on exertion. He was recommended for home PT, a home health aide, and home nursing, but Joe declined these services out of concern for encroachment on his independence. Given his heavy alcohol use, limited support, and functional limitations, the hospitalist team felt that Joe would be best served in a skilled nursing facility. As the palliative care team, we were consulted and felt that he was eligible for hospice. Joe simply wanted to go home.
Many patients like Joe experience functional decline at EOL, leading to increased care needs and transitions between sites of care.1 Some hospitalized patients at EOL want to transition directly to home, but due to their limited functioning and social support, discharge home may be deemed unsafe by health care professionals (HCPs). Clinicians then face the difficult balancing act of honoring patient wishes and avoiding a bad outcome. For patients at EOL, issues of capacity and risk become particularly salient. Furthermore, the unique structure of the US Department of Veterans Affairs (VA) health system and the psychosocial needs of some veterans add additional considerations for complex EOL discharges.2
End-of-life Decision Making
While patients may express strong preferences regarding their health care, their decision-making ability may worsen as they approach EOL. Contributing factors include older age, effects of hospitalization, treatment adverse effects, and comorbidities, including cognitive impairment. Studies of terminally ill patients show high rates of impaired decisional capacity.3,4 It is critical to assess capacity as part of discharge planning. Even when patients have the capacity, families and caregivers have an important voice, since they are often instrumental in maintaining patients at home.
Defining Risk
Determining whether a discharge is risky or unsafe is highly subjective, with differing opinions among clinicians and between patients and clinicians.5-7 In a qualitative study by Coombs and colleagues, HCPs tended toward a risk-averse approach to discharge decisions, sometimes favoring discharge to care facilities despite patient preferences.6 This approach also reflects pressures from the health care system to decrease the length of stay and reduce readmissions, important metrics for patient care and cost containment. However, keeping patients hospitalized or in nursing facilities does not completely mitigate risks (eg, falls) and carries other hazards (eg, nosocomial infections), as highlighted during the COVID-19 pandemic.7,8 The prospect of malpractice lawsuits and HCP moral distress about perceived risky home situations can also understandably affect decision making.
At the same time, risk calculation changes depending on the patient’s clinical status and priorities. Coombs and colleagues found that in contrast to clinicians, patients nearing EOL are willing to accept increasing risks and suboptimal living conditions to remain at home.6 What may be intolerable for a younger, healthier patient with a long life expectancy may be acceptable for someone who is approaching EOL. In our framework, a risky home discharge at EOL is considered one in which other adverse events, such as falls or inadequate symptom management, are likely.
Ethical Considerations
Unsafe discharges are challenging in part because some of the pillars of medical ethics can conflict. Prior articles have analyzed the ethical concerns of unsafe discharges in detail.9-11 Briefly, when patients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well. The concept of dignity of risk highlights the imperative to respect others’ decisions even when they increase the chance of harm, particularly given the overall shift in medicine from paternalism to shared decision making.12 Accommodating patient choice in how and where health care is received allows patients to regain some control over their lives, thereby enhancing their quality of life and promoting patient dignity, especially in their remaining days.13
Discharge Risk Framework
Our risk assessment framework helps clinicians more objectively identify factors that increase or decrease risk, inform discharge planning, partner with patients and families, give patients a prominent role in EOL decisions, and mitigate the risk of a bad outcome. This concept has been used in psychiatry, in which formal suicide assessment includes identifying risk factors and protective factors to estimate suicide risk and determine interventions.14 Similar to suicide risk estimation, this framework is based on clinical judgment rather than a specific calculation.
While this framework serves as a guide for determining and mitigating risk, we encourage teams to consider legal or ethical consultations in challenging cases, such as those in which patients lack both capacity and an involved HCA.
Step 1: Determine the patient’s capacity regarding disposition planning. Patients at EOL are at a higher risk of impaired decision-making capabilities; therefore, capacity evaluation is a critical step.
Step 2: Identify risk factors and protective factors for discharge home. Risk factors are intrinsic and extrinsic factors that increase risk such as functional or sensory impairments. Protective factors are intrinsic and extrinsic factors that decrease risk, including a good understanding of illness and consistent connection with the health care system (Table 1).
Step 3: Determine discharge to home risk level based on identified risk factors and protective factors. Patients may be at low, moderate, or high risk of having an adverse event, such as a fall or inadequate symptom control (Table 2).
Step 4: Identify risk mitigation strategies. These should be tailored to the patient based on the factors identified in Step 2. Examples include home nursing and therapy, mental health treatment, a medical alert system, and frequent contact between the patient and health care team.
Step 5: Meet with inpatient and outpatient HCP teams. Meetings should include the primary care professional (PCP) or relevant subspecialist, such as an oncologist for patients with cancer. For veterans receiving care solely at a local VA medical center, this can be easier to facilitate, but for veterans who receive care through both VA and non-VA systems, this step may require additional coordination. We also recommend including interdisciplinary team members, such as social workers, case managers, and the relevant home care or hospice agency. Certain agencies may decline admission if they perceive increased risk, such as no 24-hour care, perceived self-neglect, and limited instrumental support. During this meeting, HCPs discuss risk mitigation strategies identified in Step 4 and create a plan to propose to patients and families.
Step 6: Meet with patient, HCA, and family members. In addition to sharing information about prognosis, assessing caregiver capabilities and burden can guide conversations about discharge. The discharge plan should be determined through shared decision making.11 If the patient lacks capacity regarding disposition planning, this should be shared with the HCA. However, even when patients lack capacity, it is important to continue to engage them to understand their goals and preferences.
Step 7: Maximize risk mitigation strategies. If a moderate- or high-risk discharge is requested, the health care team should maximize risk mitigation strategies. For low-risk discharges, risk mitigation strategies can still promote safety, especially since risk increases as patients progress toward EOL. In some instances, patients, their HCAs, or caregivers may decline all risk mitigation strategies despite best efforts to communicate and negotiate options. In such circumstances, we recommend discussing the case with the outpatient team for a warm handoff. HCPs should also document all efforts (helpful from a legal standpoint as well as for the patient’s future treatment teams) and respect the decision to discharge home.
Applying the Framework
Our patient Joe provides a good illustration of how to implement this EOL framework. He was deemed to have the capacity to make decisions regarding discharge (Step 1). We determined his risk factors and protective factors for discharge (Step 2). His poor functional status, limited instrumental support, heavy alcohol use, rejection of home services, and communication barriers due to severe hearing impairment all increased his risk. Protective factors included an appreciation of functional limitations, intact cognition, and an involved HCA. Based on his limited instrumental support and poor function but good insight into limitations, discharge home was deemed to be of moderate risk (Step 3). Although risk factors such as alcohol use and severe hearing impairment could have raised his level to high risk, we felt that his involved HCA maintained him in the moderate-risk category.
We worked with the hospitalist team, PT, and audiology to identify multiple risk mitigation strategies: frequent phone calls between the HCA and outpatient palliative care team, home PT to improve transfers from bed to bedside commode, home nursing services either through a routine agency or hospice, and hearing aids for better communication (Steps 4 and 5). We then proposed these strategies to Joe and his HCA (Step 6). Due to concerns about infringement on his independence, Joe declined all home services but agreed to twice-daily check-ins by his HCA, frequent communication between his HCA and our team, and new hearing aids.
Joe returned home with the agreed-upon risk mitigation strategies in place (Step 7). Despite clinicians’ original reservations about sending Joe home without formal services, his HCA maintained close contact with our team, noting that Joe remained stable and happy to be at home in the months following discharge.
Conclusions
Fortunately, VA HCPs operate in an integrated health care system with access to psychological, social, and at-home medical support that can help mitigate risks. Still, we have benefitted from having a tool to help us evaluate risk systematically. Even if patients, families, and HCPs disagree on ideal discharge plans, this tool helps clinicians approach discharges methodically while maintaining open communication and partnership with patients. In doing so, our framework reflects the shift in medical culture from a patriarchal approach to shared decision-making practices regarding all aspects of medical care. Furthermore, we hope that this can help reduce clinician moral distress stemming from these challenging cases.
Future research on best practices for discharge risk assessment and optimizing home safety are needed. We also hope to evaluate the impact and effectiveness of our framework through interviews with key stakeholders. For Joe and other veterans like him, where to spend their final days may be the last important decision they make in life, and our framework allows for their voices to be better heard throughout the decision-making process.
Acknowledgments
We thank Brooke Lifland, MD, for her theoretical contributions to the concept behind this paper.
Sometimes a patient at the end of life (EOL) just wants to go home. We recently treated such a patient, “Joe,” a 66-year-old veteran with end-stage chronic obstructive pulmonary disorder (COPD), severe hearing loss, and heavy alcohol use. A neighbor brought Joe to the hospital when he developed a urinary tract infection. Before hospitalization, Joe spent his days in bed. His neighbor was his designated health care agent (HCA) and caregiver, dropping off meals and bringing Joe to medical appointments. Joe had no other social support. In the hospital, Joe could not participate in physical therapy (PT) evaluations due to severe dyspnea on exertion. He was recommended for home PT, a home health aide, and home nursing, but Joe declined these services out of concern for encroachment on his independence. Given his heavy alcohol use, limited support, and functional limitations, the hospitalist team felt that Joe would be best served in a skilled nursing facility. As the palliative care team, we were consulted and felt that he was eligible for hospice. Joe simply wanted to go home.
Many patients like Joe experience functional decline at EOL, leading to increased care needs and transitions between sites of care.1 Some hospitalized patients at EOL want to transition directly to home, but due to their limited functioning and social support, discharge home may be deemed unsafe by health care professionals (HCPs). Clinicians then face the difficult balancing act of honoring patient wishes and avoiding a bad outcome. For patients at EOL, issues of capacity and risk become particularly salient. Furthermore, the unique structure of the US Department of Veterans Affairs (VA) health system and the psychosocial needs of some veterans add additional considerations for complex EOL discharges.2
End-of-life Decision Making
While patients may express strong preferences regarding their health care, their decision-making ability may worsen as they approach EOL. Contributing factors include older age, effects of hospitalization, treatment adverse effects, and comorbidities, including cognitive impairment. Studies of terminally ill patients show high rates of impaired decisional capacity.3,4 It is critical to assess capacity as part of discharge planning. Even when patients have the capacity, families and caregivers have an important voice, since they are often instrumental in maintaining patients at home.
Defining Risk
Determining whether a discharge is risky or unsafe is highly subjective, with differing opinions among clinicians and between patients and clinicians.5-7 In a qualitative study by Coombs and colleagues, HCPs tended toward a risk-averse approach to discharge decisions, sometimes favoring discharge to care facilities despite patient preferences.6 This approach also reflects pressures from the health care system to decrease the length of stay and reduce readmissions, important metrics for patient care and cost containment. However, keeping patients hospitalized or in nursing facilities does not completely mitigate risks (eg, falls) and carries other hazards (eg, nosocomial infections), as highlighted during the COVID-19 pandemic.7,8 The prospect of malpractice lawsuits and HCP moral distress about perceived risky home situations can also understandably affect decision making.
At the same time, risk calculation changes depending on the patient’s clinical status and priorities. Coombs and colleagues found that in contrast to clinicians, patients nearing EOL are willing to accept increasing risks and suboptimal living conditions to remain at home.6 What may be intolerable for a younger, healthier patient with a long life expectancy may be acceptable for someone who is approaching EOL. In our framework, a risky home discharge at EOL is considered one in which other adverse events, such as falls or inadequate symptom management, are likely.
Ethical Considerations
Unsafe discharges are challenging in part because some of the pillars of medical ethics can conflict. Prior articles have analyzed the ethical concerns of unsafe discharges in detail.9-11 Briefly, when patients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well. The concept of dignity of risk highlights the imperative to respect others’ decisions even when they increase the chance of harm, particularly given the overall shift in medicine from paternalism to shared decision making.12 Accommodating patient choice in how and where health care is received allows patients to regain some control over their lives, thereby enhancing their quality of life and promoting patient dignity, especially in their remaining days.13
Discharge Risk Framework
Our risk assessment framework helps clinicians more objectively identify factors that increase or decrease risk, inform discharge planning, partner with patients and families, give patients a prominent role in EOL decisions, and mitigate the risk of a bad outcome. This concept has been used in psychiatry, in which formal suicide assessment includes identifying risk factors and protective factors to estimate suicide risk and determine interventions.14 Similar to suicide risk estimation, this framework is based on clinical judgment rather than a specific calculation.
While this framework serves as a guide for determining and mitigating risk, we encourage teams to consider legal or ethical consultations in challenging cases, such as those in which patients lack both capacity and an involved HCA.
Step 1: Determine the patient’s capacity regarding disposition planning. Patients at EOL are at a higher risk of impaired decision-making capabilities; therefore, capacity evaluation is a critical step.
Step 2: Identify risk factors and protective factors for discharge home. Risk factors are intrinsic and extrinsic factors that increase risk such as functional or sensory impairments. Protective factors are intrinsic and extrinsic factors that decrease risk, including a good understanding of illness and consistent connection with the health care system (Table 1).
Step 3: Determine discharge to home risk level based on identified risk factors and protective factors. Patients may be at low, moderate, or high risk of having an adverse event, such as a fall or inadequate symptom control (Table 2).
Step 4: Identify risk mitigation strategies. These should be tailored to the patient based on the factors identified in Step 2. Examples include home nursing and therapy, mental health treatment, a medical alert system, and frequent contact between the patient and health care team.
Step 5: Meet with inpatient and outpatient HCP teams. Meetings should include the primary care professional (PCP) or relevant subspecialist, such as an oncologist for patients with cancer. For veterans receiving care solely at a local VA medical center, this can be easier to facilitate, but for veterans who receive care through both VA and non-VA systems, this step may require additional coordination. We also recommend including interdisciplinary team members, such as social workers, case managers, and the relevant home care or hospice agency. Certain agencies may decline admission if they perceive increased risk, such as no 24-hour care, perceived self-neglect, and limited instrumental support. During this meeting, HCPs discuss risk mitigation strategies identified in Step 4 and create a plan to propose to patients and families.
Step 6: Meet with patient, HCA, and family members. In addition to sharing information about prognosis, assessing caregiver capabilities and burden can guide conversations about discharge. The discharge plan should be determined through shared decision making.11 If the patient lacks capacity regarding disposition planning, this should be shared with the HCA. However, even when patients lack capacity, it is important to continue to engage them to understand their goals and preferences.
Step 7: Maximize risk mitigation strategies. If a moderate- or high-risk discharge is requested, the health care team should maximize risk mitigation strategies. For low-risk discharges, risk mitigation strategies can still promote safety, especially since risk increases as patients progress toward EOL. In some instances, patients, their HCAs, or caregivers may decline all risk mitigation strategies despite best efforts to communicate and negotiate options. In such circumstances, we recommend discussing the case with the outpatient team for a warm handoff. HCPs should also document all efforts (helpful from a legal standpoint as well as for the patient’s future treatment teams) and respect the decision to discharge home.
Applying the Framework
Our patient Joe provides a good illustration of how to implement this EOL framework. He was deemed to have the capacity to make decisions regarding discharge (Step 1). We determined his risk factors and protective factors for discharge (Step 2). His poor functional status, limited instrumental support, heavy alcohol use, rejection of home services, and communication barriers due to severe hearing impairment all increased his risk. Protective factors included an appreciation of functional limitations, intact cognition, and an involved HCA. Based on his limited instrumental support and poor function but good insight into limitations, discharge home was deemed to be of moderate risk (Step 3). Although risk factors such as alcohol use and severe hearing impairment could have raised his level to high risk, we felt that his involved HCA maintained him in the moderate-risk category.
We worked with the hospitalist team, PT, and audiology to identify multiple risk mitigation strategies: frequent phone calls between the HCA and outpatient palliative care team, home PT to improve transfers from bed to bedside commode, home nursing services either through a routine agency or hospice, and hearing aids for better communication (Steps 4 and 5). We then proposed these strategies to Joe and his HCA (Step 6). Due to concerns about infringement on his independence, Joe declined all home services but agreed to twice-daily check-ins by his HCA, frequent communication between his HCA and our team, and new hearing aids.
Joe returned home with the agreed-upon risk mitigation strategies in place (Step 7). Despite clinicians’ original reservations about sending Joe home without formal services, his HCA maintained close contact with our team, noting that Joe remained stable and happy to be at home in the months following discharge.
Conclusions
Fortunately, VA HCPs operate in an integrated health care system with access to psychological, social, and at-home medical support that can help mitigate risks. Still, we have benefitted from having a tool to help us evaluate risk systematically. Even if patients, families, and HCPs disagree on ideal discharge plans, this tool helps clinicians approach discharges methodically while maintaining open communication and partnership with patients. In doing so, our framework reflects the shift in medical culture from a patriarchal approach to shared decision-making practices regarding all aspects of medical care. Furthermore, we hope that this can help reduce clinician moral distress stemming from these challenging cases.
Future research on best practices for discharge risk assessment and optimizing home safety are needed. We also hope to evaluate the impact and effectiveness of our framework through interviews with key stakeholders. For Joe and other veterans like him, where to spend their final days may be the last important decision they make in life, and our framework allows for their voices to be better heard throughout the decision-making process.
Acknowledgments
We thank Brooke Lifland, MD, for her theoretical contributions to the concept behind this paper.
1. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
2. Casarett D, Pickard A, Amos Bailey F, et al. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage. 2008;35(2):115-125. doi:10.1016/j.jpainsymman.2007.03.008
3. Kolva E, Rosenfeld B, Brescia R, Comfort C. Assessing decision-making capacity at end of life. Gen Hosp Psychiatry. 2014;36(4):392-397. doi:10.1016/j.genhosppsych.2014.02.013
4. Kolva E, Rosenfeld B, Saracino R. Assessing the decision-making capacity of terminally ill patients with cancer. Am J Geriatr Psychiatry. 2018;26(5):523-531. doi:10.1016/j.jagp.2017.11.012
5. Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nurs. 1994;19(2):249-256. doi:10.1111/j.1365-2648.1994.tb01078.x
6. Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making. Palliat Med. 2017;31(7):617-624. doi:10.1177/0269216316673476
7. Hyslop B. ‘Not safe for discharge’? Words, values, and person-centred care. Age Ageing. 2020;49(3):334-336. doi:10.1093/ageing/afz170
8. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emerg Med J. 2006;23(10):753-755. doi:10.1136/emj.2006.037903
9. Swidler RN, Seastrum T, Shelton W. Difficult hospital inpatient discharge decisions: ethical, legal and clinical practice issues. Am J Bioeth. 2007;7(3):23-28. doi:10.1080/15265160601171739
10. Hill J, Filer W. Safety and ethical considerations in discharging patients to suboptimal living situations. AMA J Ethics. 2015;17(6):506-510. Published 2015 Jun 1. doi:10.1001/journalofethics.2015.17.6.ecas2-1506
11. West JC. What is an ethically informed approach to managing patient safety risk during discharge planning?. AMA J Ethics. 2020;22(11):E919-E923. Published 2020 Nov 1. doi:10.1001/amajethics.2020.919
12. Mukherjee D. Discharge decisions and the dignity of risk. Hastings Cent Rep. 2015;45(3):7-8. doi:10.1002/hast.441
13. Wheatley VJ, Baker JI. “Please, I want to go home”: ethical issues raised when considering choice of place of care in palliative care. Postgrad Med J. 2007;83(984):643-648. doi:10.1136/pgmj.2007.058487
14. Work Group on Suicidal Behaviors. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
1. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
2. Casarett D, Pickard A, Amos Bailey F, et al. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage. 2008;35(2):115-125. doi:10.1016/j.jpainsymman.2007.03.008
3. Kolva E, Rosenfeld B, Brescia R, Comfort C. Assessing decision-making capacity at end of life. Gen Hosp Psychiatry. 2014;36(4):392-397. doi:10.1016/j.genhosppsych.2014.02.013
4. Kolva E, Rosenfeld B, Saracino R. Assessing the decision-making capacity of terminally ill patients with cancer. Am J Geriatr Psychiatry. 2018;26(5):523-531. doi:10.1016/j.jagp.2017.11.012
5. Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nurs. 1994;19(2):249-256. doi:10.1111/j.1365-2648.1994.tb01078.x
6. Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making. Palliat Med. 2017;31(7):617-624. doi:10.1177/0269216316673476
7. Hyslop B. ‘Not safe for discharge’? Words, values, and person-centred care. Age Ageing. 2020;49(3):334-336. doi:10.1093/ageing/afz170
8. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emerg Med J. 2006;23(10):753-755. doi:10.1136/emj.2006.037903
9. Swidler RN, Seastrum T, Shelton W. Difficult hospital inpatient discharge decisions: ethical, legal and clinical practice issues. Am J Bioeth. 2007;7(3):23-28. doi:10.1080/15265160601171739
10. Hill J, Filer W. Safety and ethical considerations in discharging patients to suboptimal living situations. AMA J Ethics. 2015;17(6):506-510. Published 2015 Jun 1. doi:10.1001/journalofethics.2015.17.6.ecas2-1506
11. West JC. What is an ethically informed approach to managing patient safety risk during discharge planning?. AMA J Ethics. 2020;22(11):E919-E923. Published 2020 Nov 1. doi:10.1001/amajethics.2020.919
12. Mukherjee D. Discharge decisions and the dignity of risk. Hastings Cent Rep. 2015;45(3):7-8. doi:10.1002/hast.441
13. Wheatley VJ, Baker JI. “Please, I want to go home”: ethical issues raised when considering choice of place of care in palliative care. Postgrad Med J. 2007;83(984):643-648. doi:10.1136/pgmj.2007.058487
14. Work Group on Suicidal Behaviors. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
An Interdisciplinary Approach to Metastatic Pancreatic Cancer and Comorbid Opioid Use Disorder Treatment Within a VA Health Care System
A multidisciplinary approach provided safe and feasible cancer treatment in a patient with advanced pancreatic cancer and coexisting active substance use disorder.
Substance use disorders (SUDs) are an important but understudied aspect of treating patients diagnosed with cancer. Substance use can affect cancer treatment outcomes, including morbidity and mortality.1,2 Additionally, patients with cancer and SUD may have unique psychosocial needs that require close attention and management. There is a paucity of data regarding the best approach to treating such patients. For example, cocaine use may increase the cardiovascular and hematologic risk of some traditional chemotherapy agents.3,4 Newer targeted agents and immunotherapies remain understudied with respect to SUD risk.
Although the US Department of Veterans Affairs (VA) has established helpful clinical practice guidelines for the treatment of SUD, there are no guidelines for treating patients with SUD and cancer.5 Clinicians have limited confidence in treatment approach, and treatment is inconsistent among oncologists nationwide even within the same practice. Furthermore, it can be challenging to safely prescribe opioids for cancer-related pain in individuals with SUD. There is a high risk of SUD and mental health disorders in veterans, making this population particularly vulnerable. We report a case of a male with metastatic pancreatic cancer, severe opioid use disorder (OUD) and moderate cocaine use disorder (CUD) who received pain management and cancer treatment under the direction of a multidisciplinary team approach.
Case Report
A 63-year-old male with a medical history of HIV treated with highly active antiretroviral therapy (HAART), compensated cirrhosis, severe OUD, moderate CUD, and sedative use disorder in sustained remission was admitted to the West Haven campus of the VA Connecticut Healthcare System (VACHS) with abdominal pain, weight loss and fatigue. He used heroin 1 month prior to his admission and reported regular cocaine and marijuana use (Table 1). He was diagnosed with HIV in 1989, and his medical history included herpes zoster and oral candidiasis but no other opportunistic infections. Several months prior to this admission, he had an undetectable viral load and CD4 count of 688.
At the time of this admission, the patient was adherent to methadone treatment. He reported increased abdominal pain. Computed tomography (CT) showed a 2.4-cm mass in the pancreatic uncinate process, multiple liver metastases, retroperitoneal lymphadenopathy, and small lung nodules. A CT-guided liver biopsy showed adenocarcinoma consistent with a primary cancer of the pancreas. Given the complexity of the case, a multidisciplinary team approach was used to treat his cancer and the sequelae safely, including the oncology team, community living center team, palliative care team, and interprofessional opioid reassessment clinic team (ORC).
Cancer Treatment
Chemotherapy with FOLFIRINOX (leucovorin calcium, fluorouracil, irinotecan hydrochloride, and oxaliplatin) was recommended. The first cycle of treatment originally was planned for the outpatient setting, and a peripherally inserted central catheter (PICC) line was placed. However, after a urine toxicology test was positive for cocaine, the PICC line was removed due to concern for possible use of PICC line for nonprescribed substance use. The patient expressed suicidal ideation at the time and was admitted for psychiatric consult and pain control. Cycle 1 FOLFIRINOX was started during this admission. A PICC line was again put in place and then removed before discharge. A celiac plexus block was performed several days after this admission for pain control.
Given concern about cocaine use increasing the risk of cardiac toxicity with FOLFIRINOX treatment, treating providers sconsulted with the community living center (CLC) about possible admission for future chemotherapy administration and pain management. The CLC at VACHS has 38 beds for rehabilitation, long-term care, and hospice with the mission to restore each veteran to his or her highest level of well-being. After discussion with this patient and CLC staff, he agreed to a CLC admission. The patient agreed to remain in the facility, wear a secure care device, and not leave without staff accompaniment. He was able to obtain a 2-hour pass to pay bills and rent. During the 2 months he was admitted to the CLC he would present to the VACHS Cancer Center for chemotherapy every 2 weeks. He completed 6 cycles of chemotherapy while admitted. During the admission, he was transferred to active medical service for 2 days for fever and malaise, and then returned to the CLC. The patient elected to leave the CLC after 2 months as the inability to see close friends was interfering with his quality of life.
Upon being discharged from the CLC, shared decision making took place with the patient to establish a new treatment plan. In collaboration with the patient, a plan was made to admit him every 2 weeks for continued chemotherapy. A PICC line was placed on each day of admission and removed prior to discharge. It was also agreed that treatment would be delayed if a urine drug test was positive for cocaine on the morning of admission. The patient was also seen by ORC every 2 weeks after being discharged from the CLC.
Imaging after cycle 6 showed decreased size of liver metastases, retroperitoneal lymph nodes, and pancreas mass. Cancer antigen 19-9 (CA19-9) tumor marker was reduced from 3513 U/mL pretreatment to 50 U/mL after cycle 7. Chemotherapy cycle 7 was delayed 6 days due to active cocaine and heroin use. A repeat urine was obtained several days later, which was negative for cocaine, and he was admitted for cycle 7 chemotherapy. Using this treatment approach of admissions for every cycle, the patient was able to receive 11 cycles of FOLFIRINOX with clinical benefit.
Palliative Care/Pain Management
Safely treating the patient’s malignant pain in the context of his OUD was critically important. In order to do this the palliative care team worked closely alongside ORC, is a multidisciplinary team consisting of health care providers (HCPs) from addiction psychiatry, internal medicine, health psychology and pharmacy who are consulted to evaluate veterans’ current opioid regimens and make recommendations to optimize both safety and efficacy. ORC followed this particular veteran as an outpatient and consulted on pain issues during his admission. They recommended the continuation of methadone at 120 mg daily and increased oral oxycodone to 30 mg every 6 hours, and then further increased to 45 mg every 6 hours. He continued to have increased pain despite higher doses of oxycodone, and pain medication was changed to oral hydromorphone 28 mg every 6 hours with the continuation of methadone. ORC and the palliative care team obtained consent from the veteran and a release of Information form signed by the patient to contact his community methadone clinic for further collaboration around pain management throughout the time caring for the veteran.
Even with improvement in disease based on imaging and tumor markers, opioid medications could not be decreased in this case. This is likely in part due to the multidimensional nature of pain. Careful assessment of the biologic, emotional, social, and spiritual contributors to pain is needed in the management of pain, especially at end of life.6 Nonpharmacologic pain management strategies used in this case included a transcutaneous electrical nerve stimulation unit, moist heat, celiac plexus block, and emotional support.
Psychosocial Issues/Substance Use
Psychosocial support for the patient was provided by the interdisciplinary palliative care team and the ORC team in both the inpatient and outpatient settings. Despite efforts from case management to get the veteran home services once discharged from the CLC, he declined repeatedly. Thus, the CLC social worker obtained a guardian alert for the veteran on discharge.
Close outpatient follow-up for medical and psychosocial support was very critical. When an outpatient, the veteran was scheduled for biweekly appointments with palliative care or ORC. When admitted to the hospital, the palliative care team medical director and psychologist conducted joint visits with him. Although he denied depressed mood and anxiety throughout his treatment, he often reflected on regrets that he had as he faced the end of his life. Specifically, he shared thoughts about being estranged from his surviving brother given his long struggle with substance use. Although he did not think a relationship was possible with his brother at the end of life, he still cared deeply for him and wanted to make him aware of his pancreatic cancer diagnosis. This was particularly important to him because their late brother had also died of pancreatic cancer. It was the patient’s wish at the end of his life to alert his surviving brother of his diagnosis so he and his children could get adequate screening throughout their lives. Although he had spoken of this desire often, it wasn’t until his disease progressed and he elected to transition to hospice that he felt ready to write the letter. The palliative care team assisted the veteran in writing and mailing a letter to his brother informing him of his diagnosis and transition to hospice as well as communicating that his brother and his family had been in his thoughts at the end of his life. The patient’s brother received this letter and with assistance from the CLC social worker made arrangements to visit the veteran at bedside at the inpatient CLC hospice unit the final days of his life.
Discussion
There are very little data on the safety of cancer-directed therapy in patients with active SUD. The limited studies that have been done showed conflicting results.
A retrospective study among women with co-occurring SUD and locally advanced cervical cancer who were undergoing primary radiation therapy found that SUD was not associated with a difference in toxicity or survival outcomes.7 However, other research suggests that SUD may be associated with an increase in all-cause mortality as well as other adverse outcomes for patients and health care systems (eg, emergency department visits, hospitalizations).8 A retrospective study of patients with a history of SUD and nonsmall cell lung cancer showed that these patients had higher rates of depression, less family support, increased rates of missed appointments, more emergency department visits and more hospitalizations.9 Patients with chronic myeloid leukemia or myelodysplastic syndromes who had long-term cocaine use had a 6-fold increased risk of death, which was not found in patients who had long-term alcohol or marijuana use.2
The limited data highlight the need for careful consideration of ways to mitigate potentially adverse outcomes in this population while still providing clinically indicated cancer treatment. Integrated VA health care systems provide unique resources that can maximize veteran safety during cancer treatment. Utilization of VA resources and close interdisciplinary collaboration across VA HCPs can help to ensure equitable access to state-of-the-art cancer therapies for veterans with comorbid SUD.
VA Services for Patients With Comorbidities
This case highlights several distinct aspects of VA health care that make it possible to safely treat individuals with complex comorbidities. One important aspect of this was collaboration with the CLC to admit the veteran for his initial treatment after a positive cocaine test. CLC admission was nonpunitive and allowed ongoing involvement in the VA community. This provided an essential, safe, and structured environment in which 6 cycles of chemotherapy could be delivered.
Although the patient left the CLC after 2 months due to floor restrictions negatively impacting his quality of life and ability to spend time with close friends, several important events occurred during this stay. First, the patient established close relationships with the CLC staff and the palliative care team; both groups followed him throughout his inpatient and outpatient care. These relationships proved essential throughout his care as they were the foundation of difficult conversations about substance use, treatment adherence, and eventually, transition to hospice.
In addition, the opportunity to administer 6 cycles of chemotherapy at the CLC was enough to lead to clinical benefit and radiographic response to treatment. Clinical benefits while in the CLC included maintenance of a good appetite, 15-lb weight gain and preserved performance status (ECOG [Eastern Cooperative Group]-1), which allowed him to actively participate in multiple social and recreational activities while in the CLC. From early conversations, this patient was clear that he wanted treatment as long as his life could be prolonged with good quality of life. Having evidence of the benefit of treatment, at least initially, increased the patient’s confidence in treatment. There were a few conversations when the challenges of treatment mounted (eg, pain, needs for abstinence from cocaine prior to admission for chemotherapy, frequent doctor appointments), and the patient would remind himself of these data to recommit himself to treatment. The opportunity to admit him to the inpatient VA facility, including bed availability for 3 days during his treatment once he left the CLC was important. This plan to admit the patient following a negative urine toxicology test for cocaine was made collaboratively with the veteran and the oncology and palliative care teams. The plan allowed the patient to achieve his treatment goals while maintaining his safety and reducing theoretical cardiac toxicities with his cancer treatment.
Finally, the availability of a multidisciplinary team approach including palliative care, oncology, psychology, addiction medicine and addiction psychiatry, was critical for addressing the veteran’s malignant pain. Palliative care worked in close collaboration with the ORC to prescribe and renew pain medications. ORC offered ongoing consultation on pain management in the context of OUD. As the veteran’s cancer progressed and functional decline prohibited his daily attendance at the community methadone clinic, palliative care and ORC met with the methadone clinic to arrange a less frequent methadone pickup schedule (the patient previously needed daily pickup). Non-VA settings may not have access to these resources to safely treat the biopsychosocial issues that arise in complex cases.
Substance Use and Cancer Treatments
This case raises several critical questions for oncologic care. Cocaine and fluorouracil are both associated with cardiotoxicity, and many oncologists would not feel it is safe to administer a regimen containing fluorouracil to a patient with active cocaine use. The National Comprehensive Cancer Network (NCCN) panel recommends FOLFIRINOX as a preferred category 1 recommendation for first-line treatment of patients with advanced pancreas cancer with good performance status.10 This recommendation is based on the PRODIGE trial, which has shown improved overall survival (OS): 11.1 vs 6.8 months for patients who received single-agent gemcitabine.11 If patients are not candidates for FOLFIRINOX and have good performance status, the NCCN recommends gemcitabine plus albumin-bound paclitaxel with category 1 level of evidence based on the IMPACT trial, which showed improvement in OS (8.7 vs 6.6 months compared with single-agent gemcitabine).12
Some oncologists may have additional concerns administering fluorouracil treatment alternatives (such as gemcitabine and albumin-bound paclitaxel) to individuals with active SUD because of concerns about altered mental status impacting the ability to report important adverse effects. In the absence of sufficient data, HCPs must determine whether they feel it is safe to administer these agents in individuals with active cocaine use. However, denying these patients the possible benefits of standard-of-care life-prolonging therapies without established data raises concerns regarding the ethics of such practices. There is concern that the stigma surrounding cocaine use might contribute to withholding treatment, while treatment is continued for individuals taking prescribed stimulant medications that also have cardiotoxicity risks. VA health care facilities are uniquely situated to use all available resources to address these issues using interprofessional patient-centered care and determine the most optimal treatment based on a risk/benefit discussion between the patient and the HCP.
Similarly, this case also raised questions among HCPs about the safety of using an indwelling port for treatment in a patient with SUD. In the current case there was concern about keeping in a port for a patient with a history of IV drug use; therefore, a PICC line was initiated and removed at each admission. Without guidelines in these situations, HCPs are left to weigh the risks and benefits of using a port or a PICC for individuals with recent or current substance use without formal data, which can lead to inconsistent access to care. More guidance is needed for these situations.
SUD Screening
This case begs the question of whether oncologists are adequately screening for a range of SUDs, and when they encounter an issue, how they are addressing it. Many oncologists do not receive adequate training on assessment of current or recent substance use. There are health care and systems-level practices that may increase patient safety for individuals with ongoing substance use who are undergoing cancer treatment. Training on obtaining appropriate substance use histories, motivational interviewing to resolve ambivalence about substance use in the direction of change, and shared decision making about treatment options could increase confidence in understanding and addressing substance use issues. It is also important to educate oncologists on how to address patients who return to or continued substance use during treatment. In this case the collaboration from palliative care, psychology, addiction medicine, and addiction psychiatry through the ORC was essential in assisting with ongoing assessment of substance use, guiding difficult conversations about the impact of substance use on the treatment plan, and identifying risk-mitigation strategies. Close collaboration and full utilization of all VA resources allowed this patient to receive first-line treatment for pancreatic cancer in order to reach his goal of prolonging his life while maintaining acceptable quality of life. Table 2 provides best practices for management of patients with comorbid SUD and cancer.
More research is needed into cancer treatment for patients with SUD, especially in the current era of cancer care using novel cancer treatments leading to significantly improved survival in many cancer types. Ideally, oncologists should be routinely or consistently screening patients for substance use, including alcohol. The patient should participate in this decision-making process after being educated about the risks and benefits. These patients can be followed using a multimodal approach to increase their rates of success and improve their quality of life. Although the literature is limited and no formal guidelines are available, VA oncologists are fortunate to have a range of resources available to them to navigate these difficult cases. Veterans have elevated rates of SUD, making this a critical issue to consider in the VA.13 It is the hope that this case can highlight how to take advantage of the many VA resources in order to ensure equitable cancer care for all veterans.
Conclusions
This case demonstrates that cancer-directed treatment is safe and feasible in a patient with advanced pancreatic cancer and coexisting active SUD by using a multidisciplinary approach. The multidisciplinary team included palliative care, oncology, psychology, addiction medicine, and addiction psychiatry. Critical steps for a successful outcome include gathering history about SUD; motivational interviewing to resolve ambivalence about treatment for SUD; shared decision making about cancer treatment; and risk-reduction strategies in pain and SUD management.
Treatment advancements in many cancer types have led to significantly longer survival, and it is critical to develop safe protocols to treat patients with active SUD so they also can derive benefit from these very significant medical advancements.
Acknowledgments
Michal Rose, MD, Director of VACHS Cancer Center, and Chandrika Kumar, MD, Director of VACHS Community Living Center, for their collaboration in care for this veteran.
1. Chang G, Meadows ME, Jones JA, Antin JH, Orav EJ. Substance use and survival after treatment for chronic myelogenous leukemia (CML) or myelodysplastic syndrome (MDS). Am J Drug Alcohol Ab. 2010;36(1):1-6. doi:10.3109/00952990903490758
2. Stagno S, Busby K, Shapiro A, Kotz M. Patients at risk: addressing addiction in patients undergoing hematopoietic SCT. Bone Marrow Transplant. 2008;42(4):221-226. doi:10.1038/bmt.2008.211
3. Arora NP. Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine. Am J Med Sci. 2013;345(1):45-51. doi:10.1097/MAJ.0b013e31825b2b50
4. Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. 2010;122(24):2558-2569. doi:10.1161/CIRCULATIONAHA.110.940569
5. US Department of Veterans Affairs, US Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders. Published 2015. Accessed July 8, 2021. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPGRevised22216.pdf
6. Mehta A, Chan LS. Understanding of the concept of “total pain”: a prerequisite for pain control. J Hosp Palliat Nurs. 2008;10(1):26-32. doi:10.1097/01.NJH.0000306714.50539.1a
7. Rubinsak LA, Terplan M, Martin CE, Fields EC, McGuire WP, Temkin SM. Co-occurring substance use disorder: The impact on treatment adherence in women with locally advanced cervical cancer. Gynecol Oncol Rep. 2019;28:116-119. Published 2019 Mar 27. doi:10.1016/j.gore.2019.03.016
8. Chhatre S, Metzger DS, Malkowicz SB, Woody G, Jayadevappa R. Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer. Cancer. 2014;120(21):3338-3345. doi:10.1002/cncr.28861
9. Concannon K, Thayer JH, Hicks R, et al. Outcomes among patients with a history of substance abuse in non-small cell lung cancer: a county hospital experience. J Clin Onc. 2019;37(15)(suppl):e20031-e20031. doi:10.1200/JCO.2019.37.15
10. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma. Version 2.2021. Updated February 25, 2021. Accessed July 8, 2021. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf
11. Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364(19):1817-1825. doi:10.1056/NEJMoa1011923
12. Von Hoff DD, Ervin T, Arena FP, et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013;369(18):1691-1703. doi:10.1056/NEJMoa1304369
13. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, Ren L. Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug Alcohol Depend. 2011;116(1-3):93-101. doi:10.1016/j.drugalcdep.2010.11.027
14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2013.
A multidisciplinary approach provided safe and feasible cancer treatment in a patient with advanced pancreatic cancer and coexisting active substance use disorder.
A multidisciplinary approach provided safe and feasible cancer treatment in a patient with advanced pancreatic cancer and coexisting active substance use disorder.
Substance use disorders (SUDs) are an important but understudied aspect of treating patients diagnosed with cancer. Substance use can affect cancer treatment outcomes, including morbidity and mortality.1,2 Additionally, patients with cancer and SUD may have unique psychosocial needs that require close attention and management. There is a paucity of data regarding the best approach to treating such patients. For example, cocaine use may increase the cardiovascular and hematologic risk of some traditional chemotherapy agents.3,4 Newer targeted agents and immunotherapies remain understudied with respect to SUD risk.
Although the US Department of Veterans Affairs (VA) has established helpful clinical practice guidelines for the treatment of SUD, there are no guidelines for treating patients with SUD and cancer.5 Clinicians have limited confidence in treatment approach, and treatment is inconsistent among oncologists nationwide even within the same practice. Furthermore, it can be challenging to safely prescribe opioids for cancer-related pain in individuals with SUD. There is a high risk of SUD and mental health disorders in veterans, making this population particularly vulnerable. We report a case of a male with metastatic pancreatic cancer, severe opioid use disorder (OUD) and moderate cocaine use disorder (CUD) who received pain management and cancer treatment under the direction of a multidisciplinary team approach.
Case Report
A 63-year-old male with a medical history of HIV treated with highly active antiretroviral therapy (HAART), compensated cirrhosis, severe OUD, moderate CUD, and sedative use disorder in sustained remission was admitted to the West Haven campus of the VA Connecticut Healthcare System (VACHS) with abdominal pain, weight loss and fatigue. He used heroin 1 month prior to his admission and reported regular cocaine and marijuana use (Table 1). He was diagnosed with HIV in 1989, and his medical history included herpes zoster and oral candidiasis but no other opportunistic infections. Several months prior to this admission, he had an undetectable viral load and CD4 count of 688.
At the time of this admission, the patient was adherent to methadone treatment. He reported increased abdominal pain. Computed tomography (CT) showed a 2.4-cm mass in the pancreatic uncinate process, multiple liver metastases, retroperitoneal lymphadenopathy, and small lung nodules. A CT-guided liver biopsy showed adenocarcinoma consistent with a primary cancer of the pancreas. Given the complexity of the case, a multidisciplinary team approach was used to treat his cancer and the sequelae safely, including the oncology team, community living center team, palliative care team, and interprofessional opioid reassessment clinic team (ORC).
Cancer Treatment
Chemotherapy with FOLFIRINOX (leucovorin calcium, fluorouracil, irinotecan hydrochloride, and oxaliplatin) was recommended. The first cycle of treatment originally was planned for the outpatient setting, and a peripherally inserted central catheter (PICC) line was placed. However, after a urine toxicology test was positive for cocaine, the PICC line was removed due to concern for possible use of PICC line for nonprescribed substance use. The patient expressed suicidal ideation at the time and was admitted for psychiatric consult and pain control. Cycle 1 FOLFIRINOX was started during this admission. A PICC line was again put in place and then removed before discharge. A celiac plexus block was performed several days after this admission for pain control.
Given concern about cocaine use increasing the risk of cardiac toxicity with FOLFIRINOX treatment, treating providers sconsulted with the community living center (CLC) about possible admission for future chemotherapy administration and pain management. The CLC at VACHS has 38 beds for rehabilitation, long-term care, and hospice with the mission to restore each veteran to his or her highest level of well-being. After discussion with this patient and CLC staff, he agreed to a CLC admission. The patient agreed to remain in the facility, wear a secure care device, and not leave without staff accompaniment. He was able to obtain a 2-hour pass to pay bills and rent. During the 2 months he was admitted to the CLC he would present to the VACHS Cancer Center for chemotherapy every 2 weeks. He completed 6 cycles of chemotherapy while admitted. During the admission, he was transferred to active medical service for 2 days for fever and malaise, and then returned to the CLC. The patient elected to leave the CLC after 2 months as the inability to see close friends was interfering with his quality of life.
Upon being discharged from the CLC, shared decision making took place with the patient to establish a new treatment plan. In collaboration with the patient, a plan was made to admit him every 2 weeks for continued chemotherapy. A PICC line was placed on each day of admission and removed prior to discharge. It was also agreed that treatment would be delayed if a urine drug test was positive for cocaine on the morning of admission. The patient was also seen by ORC every 2 weeks after being discharged from the CLC.
Imaging after cycle 6 showed decreased size of liver metastases, retroperitoneal lymph nodes, and pancreas mass. Cancer antigen 19-9 (CA19-9) tumor marker was reduced from 3513 U/mL pretreatment to 50 U/mL after cycle 7. Chemotherapy cycle 7 was delayed 6 days due to active cocaine and heroin use. A repeat urine was obtained several days later, which was negative for cocaine, and he was admitted for cycle 7 chemotherapy. Using this treatment approach of admissions for every cycle, the patient was able to receive 11 cycles of FOLFIRINOX with clinical benefit.
Palliative Care/Pain Management
Safely treating the patient’s malignant pain in the context of his OUD was critically important. In order to do this the palliative care team worked closely alongside ORC, is a multidisciplinary team consisting of health care providers (HCPs) from addiction psychiatry, internal medicine, health psychology and pharmacy who are consulted to evaluate veterans’ current opioid regimens and make recommendations to optimize both safety and efficacy. ORC followed this particular veteran as an outpatient and consulted on pain issues during his admission. They recommended the continuation of methadone at 120 mg daily and increased oral oxycodone to 30 mg every 6 hours, and then further increased to 45 mg every 6 hours. He continued to have increased pain despite higher doses of oxycodone, and pain medication was changed to oral hydromorphone 28 mg every 6 hours with the continuation of methadone. ORC and the palliative care team obtained consent from the veteran and a release of Information form signed by the patient to contact his community methadone clinic for further collaboration around pain management throughout the time caring for the veteran.
Even with improvement in disease based on imaging and tumor markers, opioid medications could not be decreased in this case. This is likely in part due to the multidimensional nature of pain. Careful assessment of the biologic, emotional, social, and spiritual contributors to pain is needed in the management of pain, especially at end of life.6 Nonpharmacologic pain management strategies used in this case included a transcutaneous electrical nerve stimulation unit, moist heat, celiac plexus block, and emotional support.
Psychosocial Issues/Substance Use
Psychosocial support for the patient was provided by the interdisciplinary palliative care team and the ORC team in both the inpatient and outpatient settings. Despite efforts from case management to get the veteran home services once discharged from the CLC, he declined repeatedly. Thus, the CLC social worker obtained a guardian alert for the veteran on discharge.
Close outpatient follow-up for medical and psychosocial support was very critical. When an outpatient, the veteran was scheduled for biweekly appointments with palliative care or ORC. When admitted to the hospital, the palliative care team medical director and psychologist conducted joint visits with him. Although he denied depressed mood and anxiety throughout his treatment, he often reflected on regrets that he had as he faced the end of his life. Specifically, he shared thoughts about being estranged from his surviving brother given his long struggle with substance use. Although he did not think a relationship was possible with his brother at the end of life, he still cared deeply for him and wanted to make him aware of his pancreatic cancer diagnosis. This was particularly important to him because their late brother had also died of pancreatic cancer. It was the patient’s wish at the end of his life to alert his surviving brother of his diagnosis so he and his children could get adequate screening throughout their lives. Although he had spoken of this desire often, it wasn’t until his disease progressed and he elected to transition to hospice that he felt ready to write the letter. The palliative care team assisted the veteran in writing and mailing a letter to his brother informing him of his diagnosis and transition to hospice as well as communicating that his brother and his family had been in his thoughts at the end of his life. The patient’s brother received this letter and with assistance from the CLC social worker made arrangements to visit the veteran at bedside at the inpatient CLC hospice unit the final days of his life.
Discussion
There are very little data on the safety of cancer-directed therapy in patients with active SUD. The limited studies that have been done showed conflicting results.
A retrospective study among women with co-occurring SUD and locally advanced cervical cancer who were undergoing primary radiation therapy found that SUD was not associated with a difference in toxicity or survival outcomes.7 However, other research suggests that SUD may be associated with an increase in all-cause mortality as well as other adverse outcomes for patients and health care systems (eg, emergency department visits, hospitalizations).8 A retrospective study of patients with a history of SUD and nonsmall cell lung cancer showed that these patients had higher rates of depression, less family support, increased rates of missed appointments, more emergency department visits and more hospitalizations.9 Patients with chronic myeloid leukemia or myelodysplastic syndromes who had long-term cocaine use had a 6-fold increased risk of death, which was not found in patients who had long-term alcohol or marijuana use.2
The limited data highlight the need for careful consideration of ways to mitigate potentially adverse outcomes in this population while still providing clinically indicated cancer treatment. Integrated VA health care systems provide unique resources that can maximize veteran safety during cancer treatment. Utilization of VA resources and close interdisciplinary collaboration across VA HCPs can help to ensure equitable access to state-of-the-art cancer therapies for veterans with comorbid SUD.
VA Services for Patients With Comorbidities
This case highlights several distinct aspects of VA health care that make it possible to safely treat individuals with complex comorbidities. One important aspect of this was collaboration with the CLC to admit the veteran for his initial treatment after a positive cocaine test. CLC admission was nonpunitive and allowed ongoing involvement in the VA community. This provided an essential, safe, and structured environment in which 6 cycles of chemotherapy could be delivered.
Although the patient left the CLC after 2 months due to floor restrictions negatively impacting his quality of life and ability to spend time with close friends, several important events occurred during this stay. First, the patient established close relationships with the CLC staff and the palliative care team; both groups followed him throughout his inpatient and outpatient care. These relationships proved essential throughout his care as they were the foundation of difficult conversations about substance use, treatment adherence, and eventually, transition to hospice.
In addition, the opportunity to administer 6 cycles of chemotherapy at the CLC was enough to lead to clinical benefit and radiographic response to treatment. Clinical benefits while in the CLC included maintenance of a good appetite, 15-lb weight gain and preserved performance status (ECOG [Eastern Cooperative Group]-1), which allowed him to actively participate in multiple social and recreational activities while in the CLC. From early conversations, this patient was clear that he wanted treatment as long as his life could be prolonged with good quality of life. Having evidence of the benefit of treatment, at least initially, increased the patient’s confidence in treatment. There were a few conversations when the challenges of treatment mounted (eg, pain, needs for abstinence from cocaine prior to admission for chemotherapy, frequent doctor appointments), and the patient would remind himself of these data to recommit himself to treatment. The opportunity to admit him to the inpatient VA facility, including bed availability for 3 days during his treatment once he left the CLC was important. This plan to admit the patient following a negative urine toxicology test for cocaine was made collaboratively with the veteran and the oncology and palliative care teams. The plan allowed the patient to achieve his treatment goals while maintaining his safety and reducing theoretical cardiac toxicities with his cancer treatment.
Finally, the availability of a multidisciplinary team approach including palliative care, oncology, psychology, addiction medicine and addiction psychiatry, was critical for addressing the veteran’s malignant pain. Palliative care worked in close collaboration with the ORC to prescribe and renew pain medications. ORC offered ongoing consultation on pain management in the context of OUD. As the veteran’s cancer progressed and functional decline prohibited his daily attendance at the community methadone clinic, palliative care and ORC met with the methadone clinic to arrange a less frequent methadone pickup schedule (the patient previously needed daily pickup). Non-VA settings may not have access to these resources to safely treat the biopsychosocial issues that arise in complex cases.
Substance Use and Cancer Treatments
This case raises several critical questions for oncologic care. Cocaine and fluorouracil are both associated with cardiotoxicity, and many oncologists would not feel it is safe to administer a regimen containing fluorouracil to a patient with active cocaine use. The National Comprehensive Cancer Network (NCCN) panel recommends FOLFIRINOX as a preferred category 1 recommendation for first-line treatment of patients with advanced pancreas cancer with good performance status.10 This recommendation is based on the PRODIGE trial, which has shown improved overall survival (OS): 11.1 vs 6.8 months for patients who received single-agent gemcitabine.11 If patients are not candidates for FOLFIRINOX and have good performance status, the NCCN recommends gemcitabine plus albumin-bound paclitaxel with category 1 level of evidence based on the IMPACT trial, which showed improvement in OS (8.7 vs 6.6 months compared with single-agent gemcitabine).12
Some oncologists may have additional concerns administering fluorouracil treatment alternatives (such as gemcitabine and albumin-bound paclitaxel) to individuals with active SUD because of concerns about altered mental status impacting the ability to report important adverse effects. In the absence of sufficient data, HCPs must determine whether they feel it is safe to administer these agents in individuals with active cocaine use. However, denying these patients the possible benefits of standard-of-care life-prolonging therapies without established data raises concerns regarding the ethics of such practices. There is concern that the stigma surrounding cocaine use might contribute to withholding treatment, while treatment is continued for individuals taking prescribed stimulant medications that also have cardiotoxicity risks. VA health care facilities are uniquely situated to use all available resources to address these issues using interprofessional patient-centered care and determine the most optimal treatment based on a risk/benefit discussion between the patient and the HCP.
Similarly, this case also raised questions among HCPs about the safety of using an indwelling port for treatment in a patient with SUD. In the current case there was concern about keeping in a port for a patient with a history of IV drug use; therefore, a PICC line was initiated and removed at each admission. Without guidelines in these situations, HCPs are left to weigh the risks and benefits of using a port or a PICC for individuals with recent or current substance use without formal data, which can lead to inconsistent access to care. More guidance is needed for these situations.
SUD Screening
This case begs the question of whether oncologists are adequately screening for a range of SUDs, and when they encounter an issue, how they are addressing it. Many oncologists do not receive adequate training on assessment of current or recent substance use. There are health care and systems-level practices that may increase patient safety for individuals with ongoing substance use who are undergoing cancer treatment. Training on obtaining appropriate substance use histories, motivational interviewing to resolve ambivalence about substance use in the direction of change, and shared decision making about treatment options could increase confidence in understanding and addressing substance use issues. It is also important to educate oncologists on how to address patients who return to or continued substance use during treatment. In this case the collaboration from palliative care, psychology, addiction medicine, and addiction psychiatry through the ORC was essential in assisting with ongoing assessment of substance use, guiding difficult conversations about the impact of substance use on the treatment plan, and identifying risk-mitigation strategies. Close collaboration and full utilization of all VA resources allowed this patient to receive first-line treatment for pancreatic cancer in order to reach his goal of prolonging his life while maintaining acceptable quality of life. Table 2 provides best practices for management of patients with comorbid SUD and cancer.
More research is needed into cancer treatment for patients with SUD, especially in the current era of cancer care using novel cancer treatments leading to significantly improved survival in many cancer types. Ideally, oncologists should be routinely or consistently screening patients for substance use, including alcohol. The patient should participate in this decision-making process after being educated about the risks and benefits. These patients can be followed using a multimodal approach to increase their rates of success and improve their quality of life. Although the literature is limited and no formal guidelines are available, VA oncologists are fortunate to have a range of resources available to them to navigate these difficult cases. Veterans have elevated rates of SUD, making this a critical issue to consider in the VA.13 It is the hope that this case can highlight how to take advantage of the many VA resources in order to ensure equitable cancer care for all veterans.
Conclusions
This case demonstrates that cancer-directed treatment is safe and feasible in a patient with advanced pancreatic cancer and coexisting active SUD by using a multidisciplinary approach. The multidisciplinary team included palliative care, oncology, psychology, addiction medicine, and addiction psychiatry. Critical steps for a successful outcome include gathering history about SUD; motivational interviewing to resolve ambivalence about treatment for SUD; shared decision making about cancer treatment; and risk-reduction strategies in pain and SUD management.
Treatment advancements in many cancer types have led to significantly longer survival, and it is critical to develop safe protocols to treat patients with active SUD so they also can derive benefit from these very significant medical advancements.
Acknowledgments
Michal Rose, MD, Director of VACHS Cancer Center, and Chandrika Kumar, MD, Director of VACHS Community Living Center, for their collaboration in care for this veteran.
Substance use disorders (SUDs) are an important but understudied aspect of treating patients diagnosed with cancer. Substance use can affect cancer treatment outcomes, including morbidity and mortality.1,2 Additionally, patients with cancer and SUD may have unique psychosocial needs that require close attention and management. There is a paucity of data regarding the best approach to treating such patients. For example, cocaine use may increase the cardiovascular and hematologic risk of some traditional chemotherapy agents.3,4 Newer targeted agents and immunotherapies remain understudied with respect to SUD risk.
Although the US Department of Veterans Affairs (VA) has established helpful clinical practice guidelines for the treatment of SUD, there are no guidelines for treating patients with SUD and cancer.5 Clinicians have limited confidence in treatment approach, and treatment is inconsistent among oncologists nationwide even within the same practice. Furthermore, it can be challenging to safely prescribe opioids for cancer-related pain in individuals with SUD. There is a high risk of SUD and mental health disorders in veterans, making this population particularly vulnerable. We report a case of a male with metastatic pancreatic cancer, severe opioid use disorder (OUD) and moderate cocaine use disorder (CUD) who received pain management and cancer treatment under the direction of a multidisciplinary team approach.
Case Report
A 63-year-old male with a medical history of HIV treated with highly active antiretroviral therapy (HAART), compensated cirrhosis, severe OUD, moderate CUD, and sedative use disorder in sustained remission was admitted to the West Haven campus of the VA Connecticut Healthcare System (VACHS) with abdominal pain, weight loss and fatigue. He used heroin 1 month prior to his admission and reported regular cocaine and marijuana use (Table 1). He was diagnosed with HIV in 1989, and his medical history included herpes zoster and oral candidiasis but no other opportunistic infections. Several months prior to this admission, he had an undetectable viral load and CD4 count of 688.
At the time of this admission, the patient was adherent to methadone treatment. He reported increased abdominal pain. Computed tomography (CT) showed a 2.4-cm mass in the pancreatic uncinate process, multiple liver metastases, retroperitoneal lymphadenopathy, and small lung nodules. A CT-guided liver biopsy showed adenocarcinoma consistent with a primary cancer of the pancreas. Given the complexity of the case, a multidisciplinary team approach was used to treat his cancer and the sequelae safely, including the oncology team, community living center team, palliative care team, and interprofessional opioid reassessment clinic team (ORC).
Cancer Treatment
Chemotherapy with FOLFIRINOX (leucovorin calcium, fluorouracil, irinotecan hydrochloride, and oxaliplatin) was recommended. The first cycle of treatment originally was planned for the outpatient setting, and a peripherally inserted central catheter (PICC) line was placed. However, after a urine toxicology test was positive for cocaine, the PICC line was removed due to concern for possible use of PICC line for nonprescribed substance use. The patient expressed suicidal ideation at the time and was admitted for psychiatric consult and pain control. Cycle 1 FOLFIRINOX was started during this admission. A PICC line was again put in place and then removed before discharge. A celiac plexus block was performed several days after this admission for pain control.
Given concern about cocaine use increasing the risk of cardiac toxicity with FOLFIRINOX treatment, treating providers sconsulted with the community living center (CLC) about possible admission for future chemotherapy administration and pain management. The CLC at VACHS has 38 beds for rehabilitation, long-term care, and hospice with the mission to restore each veteran to his or her highest level of well-being. After discussion with this patient and CLC staff, he agreed to a CLC admission. The patient agreed to remain in the facility, wear a secure care device, and not leave without staff accompaniment. He was able to obtain a 2-hour pass to pay bills and rent. During the 2 months he was admitted to the CLC he would present to the VACHS Cancer Center for chemotherapy every 2 weeks. He completed 6 cycles of chemotherapy while admitted. During the admission, he was transferred to active medical service for 2 days for fever and malaise, and then returned to the CLC. The patient elected to leave the CLC after 2 months as the inability to see close friends was interfering with his quality of life.
Upon being discharged from the CLC, shared decision making took place with the patient to establish a new treatment plan. In collaboration with the patient, a plan was made to admit him every 2 weeks for continued chemotherapy. A PICC line was placed on each day of admission and removed prior to discharge. It was also agreed that treatment would be delayed if a urine drug test was positive for cocaine on the morning of admission. The patient was also seen by ORC every 2 weeks after being discharged from the CLC.
Imaging after cycle 6 showed decreased size of liver metastases, retroperitoneal lymph nodes, and pancreas mass. Cancer antigen 19-9 (CA19-9) tumor marker was reduced from 3513 U/mL pretreatment to 50 U/mL after cycle 7. Chemotherapy cycle 7 was delayed 6 days due to active cocaine and heroin use. A repeat urine was obtained several days later, which was negative for cocaine, and he was admitted for cycle 7 chemotherapy. Using this treatment approach of admissions for every cycle, the patient was able to receive 11 cycles of FOLFIRINOX with clinical benefit.
Palliative Care/Pain Management
Safely treating the patient’s malignant pain in the context of his OUD was critically important. In order to do this the palliative care team worked closely alongside ORC, is a multidisciplinary team consisting of health care providers (HCPs) from addiction psychiatry, internal medicine, health psychology and pharmacy who are consulted to evaluate veterans’ current opioid regimens and make recommendations to optimize both safety and efficacy. ORC followed this particular veteran as an outpatient and consulted on pain issues during his admission. They recommended the continuation of methadone at 120 mg daily and increased oral oxycodone to 30 mg every 6 hours, and then further increased to 45 mg every 6 hours. He continued to have increased pain despite higher doses of oxycodone, and pain medication was changed to oral hydromorphone 28 mg every 6 hours with the continuation of methadone. ORC and the palliative care team obtained consent from the veteran and a release of Information form signed by the patient to contact his community methadone clinic for further collaboration around pain management throughout the time caring for the veteran.
Even with improvement in disease based on imaging and tumor markers, opioid medications could not be decreased in this case. This is likely in part due to the multidimensional nature of pain. Careful assessment of the biologic, emotional, social, and spiritual contributors to pain is needed in the management of pain, especially at end of life.6 Nonpharmacologic pain management strategies used in this case included a transcutaneous electrical nerve stimulation unit, moist heat, celiac plexus block, and emotional support.
Psychosocial Issues/Substance Use
Psychosocial support for the patient was provided by the interdisciplinary palliative care team and the ORC team in both the inpatient and outpatient settings. Despite efforts from case management to get the veteran home services once discharged from the CLC, he declined repeatedly. Thus, the CLC social worker obtained a guardian alert for the veteran on discharge.
Close outpatient follow-up for medical and psychosocial support was very critical. When an outpatient, the veteran was scheduled for biweekly appointments with palliative care or ORC. When admitted to the hospital, the palliative care team medical director and psychologist conducted joint visits with him. Although he denied depressed mood and anxiety throughout his treatment, he often reflected on regrets that he had as he faced the end of his life. Specifically, he shared thoughts about being estranged from his surviving brother given his long struggle with substance use. Although he did not think a relationship was possible with his brother at the end of life, he still cared deeply for him and wanted to make him aware of his pancreatic cancer diagnosis. This was particularly important to him because their late brother had also died of pancreatic cancer. It was the patient’s wish at the end of his life to alert his surviving brother of his diagnosis so he and his children could get adequate screening throughout their lives. Although he had spoken of this desire often, it wasn’t until his disease progressed and he elected to transition to hospice that he felt ready to write the letter. The palliative care team assisted the veteran in writing and mailing a letter to his brother informing him of his diagnosis and transition to hospice as well as communicating that his brother and his family had been in his thoughts at the end of his life. The patient’s brother received this letter and with assistance from the CLC social worker made arrangements to visit the veteran at bedside at the inpatient CLC hospice unit the final days of his life.
Discussion
There are very little data on the safety of cancer-directed therapy in patients with active SUD. The limited studies that have been done showed conflicting results.
A retrospective study among women with co-occurring SUD and locally advanced cervical cancer who were undergoing primary radiation therapy found that SUD was not associated with a difference in toxicity or survival outcomes.7 However, other research suggests that SUD may be associated with an increase in all-cause mortality as well as other adverse outcomes for patients and health care systems (eg, emergency department visits, hospitalizations).8 A retrospective study of patients with a history of SUD and nonsmall cell lung cancer showed that these patients had higher rates of depression, less family support, increased rates of missed appointments, more emergency department visits and more hospitalizations.9 Patients with chronic myeloid leukemia or myelodysplastic syndromes who had long-term cocaine use had a 6-fold increased risk of death, which was not found in patients who had long-term alcohol or marijuana use.2
The limited data highlight the need for careful consideration of ways to mitigate potentially adverse outcomes in this population while still providing clinically indicated cancer treatment. Integrated VA health care systems provide unique resources that can maximize veteran safety during cancer treatment. Utilization of VA resources and close interdisciplinary collaboration across VA HCPs can help to ensure equitable access to state-of-the-art cancer therapies for veterans with comorbid SUD.
VA Services for Patients With Comorbidities
This case highlights several distinct aspects of VA health care that make it possible to safely treat individuals with complex comorbidities. One important aspect of this was collaboration with the CLC to admit the veteran for his initial treatment after a positive cocaine test. CLC admission was nonpunitive and allowed ongoing involvement in the VA community. This provided an essential, safe, and structured environment in which 6 cycles of chemotherapy could be delivered.
Although the patient left the CLC after 2 months due to floor restrictions negatively impacting his quality of life and ability to spend time with close friends, several important events occurred during this stay. First, the patient established close relationships with the CLC staff and the palliative care team; both groups followed him throughout his inpatient and outpatient care. These relationships proved essential throughout his care as they were the foundation of difficult conversations about substance use, treatment adherence, and eventually, transition to hospice.
In addition, the opportunity to administer 6 cycles of chemotherapy at the CLC was enough to lead to clinical benefit and radiographic response to treatment. Clinical benefits while in the CLC included maintenance of a good appetite, 15-lb weight gain and preserved performance status (ECOG [Eastern Cooperative Group]-1), which allowed him to actively participate in multiple social and recreational activities while in the CLC. From early conversations, this patient was clear that he wanted treatment as long as his life could be prolonged with good quality of life. Having evidence of the benefit of treatment, at least initially, increased the patient’s confidence in treatment. There were a few conversations when the challenges of treatment mounted (eg, pain, needs for abstinence from cocaine prior to admission for chemotherapy, frequent doctor appointments), and the patient would remind himself of these data to recommit himself to treatment. The opportunity to admit him to the inpatient VA facility, including bed availability for 3 days during his treatment once he left the CLC was important. This plan to admit the patient following a negative urine toxicology test for cocaine was made collaboratively with the veteran and the oncology and palliative care teams. The plan allowed the patient to achieve his treatment goals while maintaining his safety and reducing theoretical cardiac toxicities with his cancer treatment.
Finally, the availability of a multidisciplinary team approach including palliative care, oncology, psychology, addiction medicine and addiction psychiatry, was critical for addressing the veteran’s malignant pain. Palliative care worked in close collaboration with the ORC to prescribe and renew pain medications. ORC offered ongoing consultation on pain management in the context of OUD. As the veteran’s cancer progressed and functional decline prohibited his daily attendance at the community methadone clinic, palliative care and ORC met with the methadone clinic to arrange a less frequent methadone pickup schedule (the patient previously needed daily pickup). Non-VA settings may not have access to these resources to safely treat the biopsychosocial issues that arise in complex cases.
Substance Use and Cancer Treatments
This case raises several critical questions for oncologic care. Cocaine and fluorouracil are both associated with cardiotoxicity, and many oncologists would not feel it is safe to administer a regimen containing fluorouracil to a patient with active cocaine use. The National Comprehensive Cancer Network (NCCN) panel recommends FOLFIRINOX as a preferred category 1 recommendation for first-line treatment of patients with advanced pancreas cancer with good performance status.10 This recommendation is based on the PRODIGE trial, which has shown improved overall survival (OS): 11.1 vs 6.8 months for patients who received single-agent gemcitabine.11 If patients are not candidates for FOLFIRINOX and have good performance status, the NCCN recommends gemcitabine plus albumin-bound paclitaxel with category 1 level of evidence based on the IMPACT trial, which showed improvement in OS (8.7 vs 6.6 months compared with single-agent gemcitabine).12
Some oncologists may have additional concerns administering fluorouracil treatment alternatives (such as gemcitabine and albumin-bound paclitaxel) to individuals with active SUD because of concerns about altered mental status impacting the ability to report important adverse effects. In the absence of sufficient data, HCPs must determine whether they feel it is safe to administer these agents in individuals with active cocaine use. However, denying these patients the possible benefits of standard-of-care life-prolonging therapies without established data raises concerns regarding the ethics of such practices. There is concern that the stigma surrounding cocaine use might contribute to withholding treatment, while treatment is continued for individuals taking prescribed stimulant medications that also have cardiotoxicity risks. VA health care facilities are uniquely situated to use all available resources to address these issues using interprofessional patient-centered care and determine the most optimal treatment based on a risk/benefit discussion between the patient and the HCP.
Similarly, this case also raised questions among HCPs about the safety of using an indwelling port for treatment in a patient with SUD. In the current case there was concern about keeping in a port for a patient with a history of IV drug use; therefore, a PICC line was initiated and removed at each admission. Without guidelines in these situations, HCPs are left to weigh the risks and benefits of using a port or a PICC for individuals with recent or current substance use without formal data, which can lead to inconsistent access to care. More guidance is needed for these situations.
SUD Screening
This case begs the question of whether oncologists are adequately screening for a range of SUDs, and when they encounter an issue, how they are addressing it. Many oncologists do not receive adequate training on assessment of current or recent substance use. There are health care and systems-level practices that may increase patient safety for individuals with ongoing substance use who are undergoing cancer treatment. Training on obtaining appropriate substance use histories, motivational interviewing to resolve ambivalence about substance use in the direction of change, and shared decision making about treatment options could increase confidence in understanding and addressing substance use issues. It is also important to educate oncologists on how to address patients who return to or continued substance use during treatment. In this case the collaboration from palliative care, psychology, addiction medicine, and addiction psychiatry through the ORC was essential in assisting with ongoing assessment of substance use, guiding difficult conversations about the impact of substance use on the treatment plan, and identifying risk-mitigation strategies. Close collaboration and full utilization of all VA resources allowed this patient to receive first-line treatment for pancreatic cancer in order to reach his goal of prolonging his life while maintaining acceptable quality of life. Table 2 provides best practices for management of patients with comorbid SUD and cancer.
More research is needed into cancer treatment for patients with SUD, especially in the current era of cancer care using novel cancer treatments leading to significantly improved survival in many cancer types. Ideally, oncologists should be routinely or consistently screening patients for substance use, including alcohol. The patient should participate in this decision-making process after being educated about the risks and benefits. These patients can be followed using a multimodal approach to increase their rates of success and improve their quality of life. Although the literature is limited and no formal guidelines are available, VA oncologists are fortunate to have a range of resources available to them to navigate these difficult cases. Veterans have elevated rates of SUD, making this a critical issue to consider in the VA.13 It is the hope that this case can highlight how to take advantage of the many VA resources in order to ensure equitable cancer care for all veterans.
Conclusions
This case demonstrates that cancer-directed treatment is safe and feasible in a patient with advanced pancreatic cancer and coexisting active SUD by using a multidisciplinary approach. The multidisciplinary team included palliative care, oncology, psychology, addiction medicine, and addiction psychiatry. Critical steps for a successful outcome include gathering history about SUD; motivational interviewing to resolve ambivalence about treatment for SUD; shared decision making about cancer treatment; and risk-reduction strategies in pain and SUD management.
Treatment advancements in many cancer types have led to significantly longer survival, and it is critical to develop safe protocols to treat patients with active SUD so they also can derive benefit from these very significant medical advancements.
Acknowledgments
Michal Rose, MD, Director of VACHS Cancer Center, and Chandrika Kumar, MD, Director of VACHS Community Living Center, for their collaboration in care for this veteran.
1. Chang G, Meadows ME, Jones JA, Antin JH, Orav EJ. Substance use and survival after treatment for chronic myelogenous leukemia (CML) or myelodysplastic syndrome (MDS). Am J Drug Alcohol Ab. 2010;36(1):1-6. doi:10.3109/00952990903490758
2. Stagno S, Busby K, Shapiro A, Kotz M. Patients at risk: addressing addiction in patients undergoing hematopoietic SCT. Bone Marrow Transplant. 2008;42(4):221-226. doi:10.1038/bmt.2008.211
3. Arora NP. Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine. Am J Med Sci. 2013;345(1):45-51. doi:10.1097/MAJ.0b013e31825b2b50
4. Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. 2010;122(24):2558-2569. doi:10.1161/CIRCULATIONAHA.110.940569
5. US Department of Veterans Affairs, US Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders. Published 2015. Accessed July 8, 2021. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPGRevised22216.pdf
6. Mehta A, Chan LS. Understanding of the concept of “total pain”: a prerequisite for pain control. J Hosp Palliat Nurs. 2008;10(1):26-32. doi:10.1097/01.NJH.0000306714.50539.1a
7. Rubinsak LA, Terplan M, Martin CE, Fields EC, McGuire WP, Temkin SM. Co-occurring substance use disorder: The impact on treatment adherence in women with locally advanced cervical cancer. Gynecol Oncol Rep. 2019;28:116-119. Published 2019 Mar 27. doi:10.1016/j.gore.2019.03.016
8. Chhatre S, Metzger DS, Malkowicz SB, Woody G, Jayadevappa R. Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer. Cancer. 2014;120(21):3338-3345. doi:10.1002/cncr.28861
9. Concannon K, Thayer JH, Hicks R, et al. Outcomes among patients with a history of substance abuse in non-small cell lung cancer: a county hospital experience. J Clin Onc. 2019;37(15)(suppl):e20031-e20031. doi:10.1200/JCO.2019.37.15
10. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma. Version 2.2021. Updated February 25, 2021. Accessed July 8, 2021. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf
11. Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364(19):1817-1825. doi:10.1056/NEJMoa1011923
12. Von Hoff DD, Ervin T, Arena FP, et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013;369(18):1691-1703. doi:10.1056/NEJMoa1304369
13. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, Ren L. Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug Alcohol Depend. 2011;116(1-3):93-101. doi:10.1016/j.drugalcdep.2010.11.027
14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2013.
1. Chang G, Meadows ME, Jones JA, Antin JH, Orav EJ. Substance use and survival after treatment for chronic myelogenous leukemia (CML) or myelodysplastic syndrome (MDS). Am J Drug Alcohol Ab. 2010;36(1):1-6. doi:10.3109/00952990903490758
2. Stagno S, Busby K, Shapiro A, Kotz M. Patients at risk: addressing addiction in patients undergoing hematopoietic SCT. Bone Marrow Transplant. 2008;42(4):221-226. doi:10.1038/bmt.2008.211
3. Arora NP. Cutaneous vasculopathy and neutropenia associated with levamisole-adulterated cocaine. Am J Med Sci. 2013;345(1):45-51. doi:10.1097/MAJ.0b013e31825b2b50
4. Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. 2010;122(24):2558-2569. doi:10.1161/CIRCULATIONAHA.110.940569
5. US Department of Veterans Affairs, US Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders. Published 2015. Accessed July 8, 2021. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPGRevised22216.pdf
6. Mehta A, Chan LS. Understanding of the concept of “total pain”: a prerequisite for pain control. J Hosp Palliat Nurs. 2008;10(1):26-32. doi:10.1097/01.NJH.0000306714.50539.1a
7. Rubinsak LA, Terplan M, Martin CE, Fields EC, McGuire WP, Temkin SM. Co-occurring substance use disorder: The impact on treatment adherence in women with locally advanced cervical cancer. Gynecol Oncol Rep. 2019;28:116-119. Published 2019 Mar 27. doi:10.1016/j.gore.2019.03.016
8. Chhatre S, Metzger DS, Malkowicz SB, Woody G, Jayadevappa R. Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer. Cancer. 2014;120(21):3338-3345. doi:10.1002/cncr.28861
9. Concannon K, Thayer JH, Hicks R, et al. Outcomes among patients with a history of substance abuse in non-small cell lung cancer: a county hospital experience. J Clin Onc. 2019;37(15)(suppl):e20031-e20031. doi:10.1200/JCO.2019.37.15
10. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma. Version 2.2021. Updated February 25, 2021. Accessed July 8, 2021. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf
11. Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364(19):1817-1825. doi:10.1056/NEJMoa1011923
12. Von Hoff DD, Ervin T, Arena FP, et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013;369(18):1691-1703. doi:10.1056/NEJMoa1304369
13. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, Ren L. Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug Alcohol Depend. 2011;116(1-3):93-101. doi:10.1016/j.drugalcdep.2010.11.027
14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2013.