Terminal Brain cancer and steroid management

When a patient enters stage IV of brain cancer there is no more a hospital can possibly do to rehabilitate him and the patient is told to return home. Stage IV is the final and most invasive, extreme and painful stage. In this stage the tumor has metastasized out of control in the brain, swelling the tumor until it can no longer be reversed.

In this stage, the cancerous cells creating the brain tumor metastasize wildly, producing more and more deadly cells in the brain, causing the tumor to swell intensely and overtake the brain. The tumor quickly begins to effect cognitive functions such as thinking patterns, thought processing and abilities to grasp abstract concepts. Motor skills will fail as well and the patient may fall, be unsteady and uncoordinated, and possibly suffer muscle spasm. The patient's speech patterns will deteriorate along with thoughts and he may be incoherent, stop in the middle of sentences or relate stories or sentences with no logical reason.

I spoke to Dr Lee and he suggest I increase Norman's steroid dosage as he had 2 epileptic attacks and his condition is "very serious".

There are several ways that Decadron increases at this stage can mean good palliative care for the patient...although sometimes with a mixed bag of results.

Edema elsewhere in the body has the luxury of pushing soft tissue outward or into other structures with far fewer ramifications than in the brain.There just isn't much room when swelling occurs in the brain.This swelling results in increase intracranial pressure and can cause a number of effects that begin to impact quality of life and comfort.

Occasionally, depending on the location of the tumor, this swelling will cause midline shift. The midline is a central boundary separating the left and right hemispheres. Even when tumor hasn't crossed over from one hemisphere to the other, the edema caused by the tumor's presence can still push the midline out of alignment, causing new tumor-like symptoms from this second hemisphere. When this happens, it's known as mass effect. When the midline shift is caused by swelling rather than tumor, and when the degree of shift is minimal to moderate, an increase of the steroid dose may be able to help shrink the swelling and restore the position of the midline.

How can you tell that swelling may be severe or may be under-addressed by the current dose of steroid?

The patient is sleeping excessively. When the patient is sleeping 20+ hours per day, is falling back to sleep soon after meals, dozes off even in the midst of full stimulation (eg, a room full of visitors), and seems too fatigued to enjoy things that had been previously enjoyable to him or her, this is a red flag for edema. Norman gets tire easily now and takes 2 naps in the day time.

The patient seems off the mark or fuzzy in several areas of function. One of the best indicators of swelling is when there are new symptoms or an increase in symptoms across the board, in several categories. For example, when the patient is newly incontinent, seems more confused than he or she did just days ago, is now slurring speech or leaving sentences unfinished, is fatigued, and has had a couple of falls while getting around the house, Norman fall off the chair once.

The patient is complaining of headaches, especially upon awakening. Head-ache is an easy indicator of swelling, particularly after the patient wakes up.

The patient is nauseous or vomiting. When swelling is severe, the three red flags are excessive sleep, headache, and nausea.

Maintaining an adequate steroid dose during this period can keep the patient comfortable and high-functioning for as long as possible. As the signs indicate that a previous dose is no longer adequate, requesting an increase can bring about improvements often within 48 hours.

With increases in the steroid dose, unfortunately, can come several side effects.

Mood/personality changes: Some patients experience a worsening of their mood or negative changes to their personality as the steroid dose goes up. Typical may be impatience, rudeness, sarcasm, childlike behaviors and anger.

Insomnia: Steroid perks a person up and difficulty to sleep is very common

Atrophy of the leg muscles: As the steroid dose is raised, keeping the legs moving becomes even more important, in order to keep a patient mobile for as long as possible. Physiotherapy here will help greatly.

Increased appetite: Many patients on "higher" doses of steroid experience a great increase in their appetite. Norman is eating quite well and is getting very rounded in the middle!

He is now fighting every step,refusing to give in to his skinny legs, hugh belly, swollen feet,shakiness, depression, anger, confusion, exhaustion, anxiety and poor coordination. May God gives us strength and courage to overcome this excruciatingly painful times.