Flor is a 75-year-old Latina, homosexual, cisgender woman from Puerto Rico. She identifies as having been raised Catholic, but "found my own way to God". Her wife, Rebecca Bernstein, is Jewish and about ten years her junior. Flor has one daughter, Wanda, from her previous marriage. Flor was diagnosed last year with Acute Myeloid Leukemia (AML). Over the past several months of treatment, she prepared for and received an allogeneic stem cell transplant which placed her in remission from the AML. 

During the recovery period following the stem cell transplant, Flor was in isolation in the hospital due to a diminished immune system and was treated for weakness, fatigue, and aching bone and muscle pain from therapies to encourage the regrowth of her immune system. Flor and Rebecca met at work at a school, where Flor worked as a counselor and where Rebecca is now an administrator. Flor retired at the beginning of the pandemic, while Rebecca has found her workload has increased tremendously, making focusing on Flor during her recovery very challenging. Flor's daughter Wanda, and her family (including Flor's two grandchildren), were vacationing in Australia prior to the pandemic and remained there for about 18 months. Flor connected with her daughter Wanda only virtually. Upon discharge home, Flor looked forward to spending more time with Rebecca during the summer while Rebecca was off from school. However, about two months after returning home from the hospital Flor felt a lump on her bicep. The lump grew and was red, and tender and she had an intermittent fever. Following up with her oncologist, Flor was diagnosed with post-transplant lymphoproliferative disease, a rare but known secondary cancer associated with transplants. Flor is undergoing testing to find out if the new cancer is benign or potentially life-threatening. She has expressed comments about not wanting to begin another treatment regimen after two years of near-constant treatment. You are a palliative care social worker in the outpatient clinic. You are asked to meet with Flor to support her in goals of care planning, advance directives, and psychosocial support. 

 

What are the palliative care issues presented in this case?