What's the next step for a 60-year-old patient with metastatic colorectal cancer (mets CRC) and an ileostomy, being treated for sepsis, now presenting with gastrointestinal (GI) bleeding and a Do Not Resuscitate (DNR) status?

Management of GI Bleeding in a 60-Year-Old Patient with Metastatic CRC, Ileostomy, Sepsis, and DNR Status

For a 60-year-old patient with metastatic colorectal cancer, ileostomy, sepsis, and GI bleeding who is DNR, the next step should be palliative management focused on symptom control and quality of life rather than invasive interventions. 1

Initial Assessment and Management

• Determine the source and severity of bleeding while considering the patient's DNR status and goals of care 1
• Assess hemodynamic stability - if unstable, provide fluid resuscitation with normal saline to improve comfort, which is consistent with DNR status 1, 2
• Consider early adjunctive iron support including parenteral iron to address anemia symptoms 1
• Tranexamic acid may be appropriate for recurrent bleeding, though this carries an increased risk of thrombosis 1

Palliative Interventions for GI Bleeding

• Embolization or radiotherapy may be helpful if a bleeding point can be identified and would improve quality of life 1
• For patients with short prognosis, a pragmatic approach with recurrent transfusions may be appropriate if consistent with goals of care 1
• Consider endoscopic evaluation only if findings would trigger interventions consistent with patient wishes and comfort-focused care 1, 3
• DNR status does not mean "do not treat" - treatments that provide symptom relief and improve quality of life remain appropriate 3

Comprehensive Palliative Care Approach

• Early referral to palliative care services for additional support to maintain quality of life 1
• Focus on remote monitoring of patient-reported outcome measures 1
• Prioritize minimizing pain while avoiding opioid-induced constipation 1
• For malignant bowel obstruction (if present), consider corticosteroids and octreotide 1
• Avoid unnecessary hospital attendance as patients in the last phase of life often have poor experiences with limited benefits 1

Important Considerations and Caveats

• Remember that in patients with cancer and GI bleeding, more than one-third may be bleeding from non-malignant treatable causes (varices, peptic ulcer disease, angioectasia) 1
• DNR status applies specifically to cardiopulmonary resuscitation but does not limit other treatments that may improve comfort 1, 3
• The decision-making process should align with the patient's previously expressed wishes regarding end-of-life care 4
• Avoid invasive procedures like nasogastric tube insertion unless other measures to relieve symptoms have failed 1

When to Consider More Invasive Options

• If the patient has good performance status and is not actively dying, parenteral nutrition may be considered after consultation with a gastroenterologist-led nutrition team 1
• Palliative venting gastrostomy can relieve symptoms and improve quality of life in the absence of extensive peritoneal or gastric serosal disease 1
• For bleeding tumors that significantly impact quality of life, endoscopic debulking using YAG laser can be effective but is increasingly unavailable 1

The management approach should focus on comfort measures and symptom control while respecting the patient's DNR status, with the primary goal of maintaining dignity and quality of life in this patient with advanced metastatic disease, sepsis, and GI bleeding 1, 3.