Miguel V. was a 20 y/o Hispanic male originally from a rural area of Mexico. Several years prior to being hospitalized at St. Joseph’s Medical Center, he entered the United States illegally, ended up residing in a small, mostly Hispanic, town about 40 miles outside of the urban area and worked for a local nursery and landscaping business. Spanish was his primary and preferred language and he was virtually unable to speak or understand English. Miguel’s parents lived in Mexico and he had no other family living in the area.
In May, Miguel was diagnosed with testicular cancer—stage 4 with a poor prognosis. He presented with lower extremity numbness and weakness as well as a testicular mass. He underwent a right radical inguinal orchiectomy and was discharged. One month later, he presented to a hospital in the town in which he lived with symptoms of urinary incontinence and difficulty in ambulating. He was transferred to St. Joseph’s Medical Center and admitted to a hospitalist team. He received both an oncology and radiation oncology consult.
The specialist’s opinion was that radiation and chemotherapy needed to be started immediately if any type of reversal was to occur of both the neurogenic bladder as well as the lower extremity weakness. There was considerable concern as to whether Miguel’s condition was reversible even with the most aggressive treatment. In the presence of a chaplain and the case manager (and with a bedside interpreter), the physician communicated to Miguel a summary of his condition and the recommended treatments. The physician also explained that the hoped-for outcome of treatment was not certain, that there was the possibility of treatment not helping. At this time, Miguel designated a main contact person who was the pastor of the church Miguel attended in the town where he lived. However, Miguel himself was looked to by his physicians for decisions about whether to accept or refuse treatments, including, as his condition worsened, CPR.
From June to November, Miguel was hospitalized 141 of 161 days. An MRI of the lumbar spine showed complete involvement of the L5 vertebral body with extension into the epidural space and compression of the L5 region. The cancer extended into the inferior sacrum with erosion through the sacrum. Miguel underwent chemotherapy and radiation treatment. He had a 10 day stay in the intensive care unit due to infection and c. diff colitis. He had a total colectomy with ileostomy and G-tube placement. He developed megacolon.
Miguel was discharged for three days in August, but returned for a new onset of seizures. Etiology was unknown. He was discharged again for two weeks and returned to St. Joseph’s in October for further chemotherapy, though there was and had been concern on the part of some on the medical team that the chemo was of little or no benefit. Pain was becoming more of an issue. Because of his illegal immigration status and his lack of a social security number or identification, Miguel had no access to opioid prescriptions. The Palliative Care Service was consulted to assist in pain management and to assist with the very difficult issues of how Miguel was going to be cared for outside of the hospital.
The Palliative Care Service believed that Miguel, given his condition and prognosis, required good end-of-life care and that hospice would be best able to provide it. However, no hospice in the area would accept Miguel, partly because he was uninsured and partly because of the difficulty with opioids and the inability to get prescriptions filled.
A critical juncture had been reached about what was best for Miguel and how best to provide for his needs. To this point, the total cost of Miguel’s medical care to St. Joseph’s Medical Center was $500,000. (This is an adaptation of an actual case. Some details have been omitted or changed in order to maintain confidentiality of the facility and the patient).