Table 2 Vignette Summaries

1. African American

Inpatient

Summary: 71 year-old man with metastatic gastric cancer. He was living in a skilled nursing facility after a long hospitalization for infection. He is now hospitalized with recurrent fever, respiratory distress, and anxiety.

2. White

Key Question: How to manage anxiety and respiratory distress in a patient with advanced cancer and high risk for short-term death.

3. African American

Inpatient

Summary: 68 year-old woman with recurrent, metastatic pancreatic cancer and mild dementia. She is scheduled to start palliative chemotherapy next week. She presents to the ED with declining performance status, decreased appetite, and abdominal pain. Her hospital evaluation demonstrates poor kidney function, low blood pressure, and rapid breathing – all worrisome for rapid constitutional decline.

4. White

Key Question: How to manage a patient with an aggressive cancer presenting to the emergency department with multiple signs of constitutional decline.

5. African American

Medical Oncology

Summary: 75 year-old man with advanced, metastatic colon cancer. He is married and lives at home with his wife. He presents to clinic with pain, weight loss, and signs of cancer progression. He asks, “Do you think the chemo is working?”

6. White

Key Question: How to answer patient questions about prognosis and next steps in treatment of advanced cancer with limited treatment options.

7. African American

Radiation Oncology

Summary: 75 year-old man with a new diagnosis of metastatic renal cell carcinoma. He presents with seizures, brain metastases, and lung metastases. He is unmarried and without children. His performance status is poor and he is not able to make his own health care decisions. His eldest brother is his durable power of attorney, and asks, “Doc, what would you do if he was your brother?”

8. White

Key Question: How to approach surrogate decision making about management approach for a patient with poor prognosis.

9. African American

Surgical Oncology

Summary: 73 year-old man with newly diagnosed non-metastatic lung cancer. He has severe lung disease and significant vascular disease from heavy smoking. He is a poor surgical candidate. He mentions that the stress of his cancer diagnosis has caused him to drink alcohol more heavily than usual and he is coughing up about 1–2 tablespoons of bright red blood daily.

10. White

Key Question: How to approach a patient with a new diagnosis of a potentially curable cancer when there are a number of red flags that the patient may do poorly with surgical treatment.

11. African American

Outpatient

Summary: 68 year-old woman with a recent diagnosis of pancreas cancer. She has been hospitalized with weight loss, pain, and declining activity. Her evaluation shows a “borderline resectable” pancreatic cancer (initial treatment would be chemotherapy or chemoradiation, if she could tolerate this). She has been unable to eat or ambulate for the last five days, due to poor appetite and performance status. She says, “I’m a fighter, not a quitter” and “With Jesus, anything is possible.” She then asks, “What comes next?”

12. White

Key Question: How to approach a patient who has a “treatable” diagnosis, but who does not have the performance status to tolerate treatment.