May 31, 2005

Integrated Care: A Case Presentation

By Edwin Moore, DO and Michael Moore, AP

Medicine, both Eastern and Western, has long been a closed society. The knowledge that each form of medicine applied to patient care was considered the correct approach, and any deviations considered unorthodox.

Today, the walls that separate the two are collapsing as practitioners from both sides of the house are uniting into integrated practices. The object of integrated medicine is to provide the patient with much greater treatment options than are available through Eastern or Western medicine alone. The net result is a markedly greater knowledge base from which to address patient care.

At present, the experience of integrated care medicine is limited. As physicians from Eastern and Western backgrounds continue to recognize and consult each other, the net result will be medical care, tailored to the patient's malady, which will act synergistically. This paper represents a case presentation of a patient who required the application of both Eastern and Western medicine for relief of his suffering.

D.H. was a 65-year-old white male who had enjoyed excellent health until the fall of 1999. At that time, he developed diarrhea. He was seen by his family doctor, who made a diagnosis of benign diarrhea. The patient's symptoms continued for another week. At that point he developed severe abdominal pain, as well as nausea and vomiting. He was seen in the local emergency department, where a diagnosis of a large bowel obstruction was made. The patient's symptoms continued, and he was taken to surgery.

At the time of surgery, an adenocarcinoma of the colorectal region was discovered. It was also noted that the patient had metastatic involvement throughout the peritoneum. A bowel resection with a colostomy was preformed. D.H. was scheduled for follow up with outpatient chemotherapy. His hospital course was uneventful. He was released from the hospital relatively pain free.

The week following his release from the hospital, he developed jaundice and severe nausea and vomiting. He was seen by his surgeon for follow-up care. The patient had developed jaundice to the point that it was felt that chemotherapy would not alter the clinical course, nor could it offer the patient any significant benefit. The patient was referred to a hospice for care. Over the ensuing several weeks, the patient's jaundice escalated, as did the nausea. The family requested the authors to become involved to see if the patient could be offered any relief with traditional Chinese medicine.

The authors manage an integrated medical care facility with an emphasis in family medicine. Western and Eastern medicine are practiced in concert in approximately 60 percent of the patient base. As an integrated practice, both physicians examined the patient. The Western diagnosis was metastatic disease with obstructive jaundice. The TCM diagnosis was yang-type bright yellow damp heat in the liver and gallbladder. At the time of involvement, the patient was having uncontrolled pain as well as severe nausea and vomiting. His medications for nausea and vomiting were either ineffective, or the side-effects were not tolerated. An integrated treatment program was developed to address the patient's physical, emotional and spiritual needs during this period, the closure of his life.

Worldwide, colorectal cancer is one of the leading causes of death. It is much more prevalent in developed countries than in developing countries. It is estimated that adenocarcinoma comprises 98 percent of all large bowel cancers. The peak incidence occurs between the ages of 60 to 70 years. Also of interest are the dietary factors which are related to a higher incidence of large bowel cancer. These include a low content of unabsorbable vegetable fiber, a high refined carbohydrate content, high fat content, and a decrease of protective micronutrients. The speculation is that those diets with the above factors cause an alteration of bowel flora. In addition, these foods contain less vitamins A, C, and E. With lower levels of these naturally occurring antioxidants, the chance of malignant degeneration increases.

In traditional Chinese medicine, the term fu liang refers to gastrointestinal carcinoma. It is of interest that this is translated as "stagnation under the heart." The thought is that the cancer is caused by stagnation of blood and qi. Following the Western dietary model, a direct comparison can be made between the stagnation under the heart and the slow rate of stool passage due to a low-fiber diet, or bacterial overgrowth and poor antioxidant concentrations.

The first issue to be addressed was the patient's chief complaint, intractable nausea and vomiting. The etiology of the patient's nausea and vomiting was felt to be multifactorial, although several etiologies were eliminated. Narcotic-induced nausea was eliminated since the patient had not been on narcotics at the time of the initial evaluation. In the hospital, two months prior to the initial evaluation, the patient had a CT scan of the head, which appeared without any space-occupying lesions. The etiology of increased intercranial pressure was dismissed. Although the patient had a colostomy, the examination of his abdomen was otherwise benign. Thus, nausea secondary of an obstruction was ruled out.

It was felt that the patient's nausea and vomiting were secondary to his obstructive jaundice and his metastatic disease. Metoclopramide (Reglan) had been used for control without success. Prochlorperazine (Compazine) had caused a dystonic reaction. Trimethobenzamide (Tigan) was not effective. Promethazine (Phenergan) was effective; however, it caused excessive sedation. The patient was treated with acupuncture, which offered significant relief without sedation. At one point, the patient had breakthrough nausea. "Pill curing" was added as an "as-needed" medication for relief of breakthrough nausea and vomiting.

The initial and second acupuncture treatments involved needling of P 6 and LI 4. These remained the basic treatment sites. As the patient's condition changed, the acupuncture prescription was modified. When it was observed that the patient was receiving the additional benefit of pain relief, the treatment sites were expanded. Along with continuing stimulation of P 6 and LI 4, SI 7 (right), SI 9, SI 10 and SI 13 were added.

The literature regarding the specific use of acupuncture in the nausea and vomiting that accompanies metastatic disease is sparse. There are many studies documenting the use of acupuncture in the treatment of nausea and vomiting. One such study states that the use of acupuncture in the treatment of nausea has been proven unequivocally. Further, Dundee and McMillian demonstrated the effectiveness of stimulation of P 6 for the relief of morning sickness. The stimulation of this point was also shown to be effective in the control of postoperative nausea and vomiting by Schlager. Schlager has also observed acupuncture's freedom of side-effects.

The question of the mechanism of acupuncture's role arises. According to Hanping, "Acupuncture/moxibustion assist the intrinsic regulatory potentials to normalize the abnormal of the effect of the regulatory system in the body." Few can debate the disrupted homeostasis involved in metastatic disease. It would appear that acupuncture is in some manner able to affect neurohumeral changes that relieve the symptoms. This may be through the release of enkaphalins and dynorphins, which act centrally to relieve the nausea. There may be some peripheral pathway that remains to be elucidated.

The second issue to be addresses with the patient was pain control. The patient had been on prophephene on an as needed basis. The family did not understand the dosing schedule. During this time, the patient was suffering from severe nausea and vomiting. The net result was that the patient was not receiving any pain relief. To address this, the patient was placed on a constant dose of morphine sulfate. Added to this was a sliding-scale titration schedule that allowed the patient to adjust his medication needs. The sliding-scale schedule was explained to the family and caretakers. With this mechanism, the patient titrated his morphine requirements to the level that he had pain relief without excessive sedation.

Of interest was the finding that the patient's requirement for morphine was less following acupuncture. Following a low dose of morphine and an acupuncture treatment, the patient was alert and pain-free, without nausea and vomiting. Ji-Sheng Han at Beijing Medical University found stimulation of acupuncture sites resulted in both opioid and non-opioid receptor response in the central nervous system. This finding correlates with the patient's report that his need for supplemental morphine occurred primarily at night, the time most removed from his acupuncture treatments.

The third point to be addressed was emotional support for the patient. The patient was married and had a son who had come to be with him during this time. Family members were also present. A significant factor was the local hospice which presented to care for the patient. Through the hospice, family members were taught and guided in the correct techniques to assist the patient in coping with his terminal disease. Prior to hospice involvement, the support system was ineffective. This was due to the fear and uncertainty based upon ignorance. The hospice personnel were patient and kind. They acted as tour guides for both the patient and his family, leading them down an unfamiliar path. The patient and the family offered great praise for the hospice. Although not a part of this practice, they significantly added to the integrated-care approach to the patient.

The final aspect to be addressed was the patient's spiritual needs. The patient was a devoted Christian who was active in his church. The patient believed in forgiveness of sin, as well as a life after death. To the patient, death did not represent an end, but rather a beginning. Members of the church came to the patient's home during his illness to offer support to both the patient and his family. They would read the Bible together and have group prayer. Although the patient's spiritual beliefs were already deeply entrenched at the time of his illness, the support provided by his church offered immeasurable comfort.

Integrated care is a concept whereby healing professionals from different backgrounds confer to develop a treatment plan individualized to the patient's specific malady. By necessity, this involves interaction with programs to which the physician is not familiar. In the past, physicians were reluctant to consider treatment programs outside of their own system of training. Today, patient demands are forcing them to reconsider this position. The purpose of integrated care is not to replace "mainstream" medicine but instead to expand it to other treatment options. The end result is improved patient care.


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