Cancer Care History and Management Flashcards
Outline the SPIKES mnemonic for breaking bad news
Setting
Perception
Invitation
Knowledge
Empathy
Strategy and Summary
Outline the SETTING part of the SPIKES mnemonic
Ensure it is in a private place and sitting down!
‘I was hoping to have a conversation with you, are you okay to have that discussion right now? is it alright if we do it here? Would you like a family member or friend with you?’
Outline the PERCEPTION part of the SPIKES mnemonic
Discuss the sequence of events up to this point
What do you know already about what’s been happening?
Give a warning shot:
“Symptoms like the ones you’ve been describing can sometimes be as a result of … , but sometimes they can be as a result of more serious underlying conditions”
Outline the INVITATION part of the SPIKES mnemonic
Check if the patient wants to receive their results today – “I have the result here today, would you like me to explain it to you now?”.
Outline the KNOWLEDGE part of the SPIKES mnemonic
Use a warning shot to indicate that you have bad news: “As you know we took a biopsy/did a scan, and unfortunately the results were not as we hoped”.
Pause so the patient can digest the information
Provide the diagnosis using simple language: “I’m sorry to tell you this, but the results from the investigations show you have cancer”.
Outline the EMPATHY part of the SPIKES mnemonic
Give the patient time to take everything in
‘I can see that this is not the news that you expected, I’m so sorry’
‘I know this is a lot to take in, I am here to support you through this and answer any questions you might have’
What can you say if a patient asks you a question that you can’t answer e.g. about their prognosis?
“I’m so sorry, but at this stage, I don’t have enough information to answer that. Hopefully in the next few weeks once we’ve completed other tests I can be clearer. Sorry, I can appreciate that it’s frustrating to be left with unanswered questions’
Outline the STRATEGY AND SUMMARY part of the SPIKES mnemonic
Inform them of the follow-up arrangements:
‘I am going to refer you to…. ‘
or
‘ I will see you back in clinic so that we can have another conversation once you’ve had some time to process’
Check the patient’s understanding of the bad news you have delivered - ‘ I appreciate once you’ve heard news like this it can be hard to take in what someone is saying - is there anything you didn’t quite understand or would like me to clarify? ‘
‘If you would like me to help you to tell family or friends about this news I am happy to help’
‘If you have any more questions when you’re home you can talk to our clinical nurse specialists’
‘You can find out more information online at…’
What questions should you ask to explore someone’s cancer history before delving into the presenting complaint?
When were you diagnosed?
What treatment have you been receiving and when did have it?
When did you last see someone about your cancer?
How are your symptoms and how are you managing?
What questions should you ask a cancer patient who is presenting with shortness of breath?
Onset of SOB? Gradual or acute? Aggravating and relieving factors?
Systematically ask questions to rule in/ out differentials:
When was recent treatment? (pneumonitis)
Swelling of face or neck? (SVCO)
Chest pain? (PE, pneumothorax, MI)
Chest pain w radiation down arm? Palpitations? Syncope? (Cardiac cause)
New cough? Productive? Haemoptysis?
Fever? (pneumonia)
Leg swelling? (DVT)
What may cause shortness of breath in a patient with cancer?
cancer itself- SVC0 (emergency!), lung mets, primary lung cancer, malignant pleural effusion
cancer tx - respiratory depression from opiate use, pneumonitis
other - pneumonia, PE, pneumothorax, cardiac, asthma / COPD
How can you explain a malignant pleural effusion to a patient?
there is a collection of fluid around your lungs, which we call a pleural effusion
this is stopping your lungs from expanding fully which is why you feel so short of breath
unfortunately, when this happens it usually has quite a serious underlying cause…
this usually suggests that your cancer has spread to the lining of your lungs
How can you explain management of a malignant pleural effusion to a patient?
What we can do is insert a drain to allow all of that fluid to escape and allow your lungs to expand fully, which will hopefully mean that you feel less short of breath
explain that this does not get rid of the underlying cancer and you will need to speak to the whole oncology team to decide on a plan going forwards - usually by the time people have pleural effusion we are looking at a non-curative mx of cancer
explain that any planned surgery cannot go ahead as malignant pleural effusion is a contraindication
What do you need to ask when a cancer patient is presenting with pain? (beyond SQITARS)
Need to assess the impact of pain on the patient day to day, their understanding of the cause of the sxs (do they assume that escalating pain means that their cancer is spreading?), what management has been tried, do they have any concerns about proposed tx
How would you address patient concerns about opioid use including addiction, tolerance and hastening of death?
Many patients are concerned about becoming addicted to opioids: if it is taken as prescribed for pain there is a low risk of becoming dependent, if they are using it for other reasons for example to sedate themselves at night then risk of addiction increases
Patients also worry about tolerance: giving opioids early to get on top of pain does not increase risk of worse pain down the line
No evidence that opioids shorten life: Good pain relief can lengthen life- allows to stay active for longer, keep eating and drinking
What key opioid side effects should you make a patient aware of?
Constipation – on-going, prescribe with laxatives
Nausea and Vomiting – only in 1/3 of patients, usually transient, lasts up to a week, can prescribe an antiemetic PRN alongside
Dry mouth – on-going, can be managed with ice-lollies, sugar free sweets, chewing gum
Sedation – usually at the start of new dose, lasts 2/3 days
Respiratory depression – suddenly giving a very high dose increases risk, AKI may precipitate (No increased risk at end of life, relatively rare)
How could you answer a patient who asks ‘ what can I expect to experience at the end of life’?
Everybody is different but some of the things that people commonly experience as they come towards the end of their life include:
Sleepiness and difficulty waking
Restlessness
Feeling confused
Difficulty swallowing or not wanting to eat or drink at all
Feeling sick
Loss of bladder and bowel control
Changes in breathing
But it is our job to keep you comfortable and there are medications that we can prescribe the reduce these symptoms.
Is there anything you are particularly worried about?
Is there anyone that you would like to have present at the end of your life? Family, friends, faith leaders?
What 5 common symptoms should you prescribe for in anticipation in an end of life patient?
Pain – morphine 2.5-5mg
Breathlessness / changes in breathing (e.g. Cheynes-Stokes irregular breathing) – morphine 2.5-5mg
Nausea and vomiting – levomepromazine 2.5-5mg
Terminal agitation – midazolam 2.5-5mg, consider haloperidol if hallucinating
Respiratory secretions – glycoperronium 200-400mcg (less sedating and doesn’t cross BBB)
How can you answer a patient who asks ‘ how long have I got left’?
Oh gosh, that’s a big question. Is it Ok if I ask what prompted you to ask that?
Unfortunately, I don’t have all the answers and I can’t give you a specific timeline, but when people start to have symptoms like ….. it is likely that time is very short.
How should you respond to a patient with cancer who asks ‘ is this my fault’?
Cue to explore concerns:
Can I ask, what makes you say that?
Why are you worried that this is your fault?
Cancer is not anybody’s fault. Unfortunately, sometimes it just happens.
If they are concerned about a particular risk factor – e.g., is it my fault I have lung cancer because I have smoked?
As you probably already know, smoking is a risk factor for lung cancer. But there are people who never smoke who get lung cancer, and there are people who chain smoke who don’t, so sometimes these things are not within our control. I don’t think it is helpful for you to blame yourself for what has happened. What’s happened has happened, and I think we should focus on looking after you and keeping you as comfortable as possible.
What questions should you ask a patient presenting with bone pain?
SQITARS
Impact on daily life and mobility
Screen for hypercalcaemia:
tummy pain, N+V, constipation?
change in appetite, inc thirst?
inc urination?
muscle twitches?
feeling more tired or confused?
Assess their understanding of the cause of the sxs (do they assume that escalating pain means that their cancer is spreading?)
What management has been tried?
What managment options can you suggest for someone with bone pain due to bone mets?
NSAIDs
bisphosphonates - type of medication that can slow down or prevent bone damage and lower calcium levels
radiotherapy
You should always have a high index of suspicion for any cancer patients (especially those with known bone mets) who might have hypercalcaemia.
What symptoms may it present with?
How does this present on bloods and ECG?
How should you manage this?
‘bones, stones, groans and psychic moans’
fractures, renal stones, GI upset, confusion / lethargy
Calcium level over 2.5
Short QT interval
rehydration with normal saline, typically 3-4 litres/day
then bisphosphonates (e.g. Pamidronate) , takes 2-3 days to work
calcitonin works faster
Lung Cancer + confusion, nausea and weakness =
likely hypercalcaemia
Ix: measure serum calcium!!!
can also do an ECG
Mx: IV fluids + Pamidronate (bisphosphonate) infusion over 30-60 mins
