Dying (and cancer)

Question 1

What is the epidemiology of dying?

Answer 1

• 500,000 people die in England each year
• ⅔ deaths in people over 75 years
• Rise in female as opposed to male deaths (but more men die each year)
• Majority follow period of chronic illness

Question 2

What chronic illnesses does death follow?

Answer 2

• CVD
• Cancer
• Chronic resp disease
• Stroke
• Neurological disease
• Dementia

Question 3

What are the 4 causes of cancer causing syndromes?

Answer 3

1. Primary tumour
2. Distant mets
3. Body’s responses to tumours
4. Treatment for the above

Question 4

What can distant mets cause?

Answer 4

Paraneoplastic syndromes

Question 5

What can the bodys response be?

Answer 5

a) Systemic inflammatory response
i) Explains why 2 people with same cancer may have different responses
ii) White cell / humoral response
iii) IL-6 (1 to a lesser extent)
iv) Impacts on brain/muscle/brain function, appetite, fatigue

b) Polysystem changes
i) Neuroendocrine
ii) Haematopoietic
iii) Metabolic
iv) Hepatic

Question 6

What are the neuroendocrine changes that may occur?

Answer 6

(1) Fever
(2) Somnolence → strong desire for sleep
(3) Anorexia
(4) ↑Cortisol + Catecholamines

Question 7

What are the haematopoietic changes that may occur?

Answer 7

(1) Anaemia
(2) Leucocytosis
(3) Thrombocytosis

Question 8

What are the metabolic changes that may occur?

Answer 8

(1) Cachexic - loss of striated muscle, -ve nitrogen balance
(a) From the end of the bed, temporalis and masseter muscles go in the very ill (look drawn). Muscles have the same power but lose bulk (grip is strong).
(2) ↑ lipolysis

Question 9

What are the hepatic changes that may occur?

Answer 9

(1) ↑ Acute phase proteins - High ferritin and CRP
(2) ↑ Blood flow
(a) Albumin will drop - the lower the albumin the more sick patients are (not down to liver failure or malnutrition - the liver synthetic processes are directed elsewhere - albumin infusions will not fix the underlying problem)

Question 10

What is the exponential growth theory of cancer?

Answer 10

Cancer is a lump growing steadily - there are no symptoms in the early stages. Often tumour lumps reach a critical mass, after which they stop growing. When a certain size is reached, cancer will start to cause symptoms.

Question 11

Summarise cancer

Answer 11

• Similarity to infectious disease
• Exponential growth of tumour cells
• Immune/inflammatory response to cancer
• Biochemical changes: falling albumin, falling creatinine, anaemia
• Cancers cause symptoms because:
• SIADH (affects adrenals), hypercalcaemia, hypoadrenalism, GIT dysfunction

Question 12

What is the time course progression of organ diseases vs cancer?

Answer 12

1) Single organ: heart, renal, COPD
- Start off ok, body takes a hit, but intermittent deterioration (e.g. infectious exacerbations of COPD), recover but not fully. A more significant exacerbation will kill them later on.
2) Cancer
- The tumour burden grows
- Not noticed until tumour reaches a critical mass → symptoms start
- Initially symptoms worsen from month to month, then week to week, then day to day, then hour to hour
- The diagram is wrong, things do not tail off

Question 13

Do we over or under estimate prognosis in cancer patients?

Answer 13

Over estimate

Question 14

How do we predict likely changes of survival?

Answer 14

Take median survival and multiply by half or double → covers 75% of patients
Patients who do very well - multiply median survival by 3
Patients who don’t do very well - multiple by a ¼

Question 15

When do we get palliative care involved?

Answer 15

• If cancer is life-limiting, then at some point they will need palliative care.
• Curative and palliative care should not be mutually exclusive.

Question 16

How do you assess a dying cancer patient?

Answer 16

• Take a good history / narrative

- Use a structure for the history

Question 17

What physical symptoms might a cancer patient get?

Answer 17

SYMPTOM	Lung Cancer(%)
Fatigue	50-90%
Pain	50-90%
Breathlessness	45-90%
Anorexia	35-75%
Cough	30-80%
Constipation	30-60%
Depression	15-70%
Nausea	15-45%
Insomnia	10-60%
Anxiety	10-45%

Question 18

How do we appraoch symptom occurrence?

Answer 18

1. What is the cause?
2. How does it affect the person?
3. What if anything should I do about it?
   a. They may not be the biggest problem for the patient
   b. A patient may want to go away or not be sleepy from medications so tailor to the pt
   c. You are not expected to have all the answers.
   d. You are expected to have a grasp of what is going on and have some understanding of what you might do next.

Question 19

What do you do if someone asks you for a management plan?

Answer 19

• If anyone asks how you would investigate (or Mx) problem ‘x’ remember the phrase:
• ‘I would start by taking a full history, then examining the patient and then consider further investigations…’
• Before talking about specific tests
• Cancer patients are no different - always take a history for a new symptom

Question 20

What is a good surgical sieve?

Answer 20

●	V: vascular
●	I: infective/Inflammatory
●	T: traumatic
●	A: autoimmune
●	M: metabolic
●	I: iatrogenic/idiopathic
●	N: neoplastic
●	C: congenital
●	D: degenerative/developmental
●	E: endocrine/environmental
●	F: functional

Question 21

What is pain and how do we approach it in palliative care?

Answer 21

• Is subjective
• 80-90% palliated by relatively simple means
• Causes: multimodal, integrative, dynamic
• Rx: depends on full assessment
• Multimodal approaches: pharmacological, physical, psychological Rx (dynamic and responsive to change)
• Is physical / discomfort
• Perception of pain
• 25% don’t have pain
• 33% have 1 pain, 33% 2 or more, 33% 3 or more pains (so survey for other pains)

Question 22

What is the WHO ladder?

Answer 22

• Step 1: Non-opioid → paracetamol, NSAIDs (± adjuvant)
  If pain persists or increases:
• Step 2: Opioid - mild to mod pain (± adjuvant + non-opioid)
  If pain persists or increases:
• Step 3: Opioid - mod to severe pain (± adjuvant + non-opioid)
• For palliative cancer patients, skip step 2 (codeine etc) → morphine (not dangerous). Morphine: only 10x stronger than codeine.
  *Adjuvant: antidepressants, anti-seizure medications, muscle relaxants, sedatives or anti-anxiety medications, and botulinum toxin.

Question 23

What is fatigue?

Answer 23

• Common symptom >80% advanced cancer patients
• Common in all advanced illness
• Not reversible with sleep/stimulants
• Limits functional ability
• Two responses
• 1. Spread themselves thinly throughout the day
• 2. Sleep and then wake up in short bursts
• Treatment
• Graded physical exercise
• No drugs have any evidence for long term benefit
• Give psychoeducation: learn to pace themselves, physiotherapy BEFORE drugs

Question 24

What is cachexia?

Answer 24

• Advanced disease driven cachexia
• Not reversible with nutrition
• No place for TPN or NG feed
• Altered cytokine and metabolic state
• Short term benefit:
• Dexamethasone, megestrol (progesterone), venlafaxine (SNRI)
• No evidence for muscle gain, only fluid retention
• Be skeptical with anabolic steroids, which may have some benefit
• Exception may be androgens

Question 25

How do patients react to a changing condition?

Answer 25

1) Must discuss with patient about how their body will change after failure of other treatments. This causes panic and distress. 2) Ensure people feel in control of how they feel. 3) Stages of change: a) Pre contemplation Denial b) Contemplation ‘Maybe’; Need to talk things through c) Determination/preparation Motivation; heads around problem d) Action Doing it e) Maintenance Living it f) Relapse/recycle Start over; Need more time to think

Question 26

What are the orders of hope?

Answer 26

● First order: denial of symptoms → hope for recovery ● Second order: denial of non-recovery → hope beyond recovery - for dignity - to be free of pain - leaving a legacy ● Third order: hope in the face of existential extinction - Chooses and affirms a stance concerning the Meaning of Life that allows them to choose what to Hope for.

Question 27

What is the spiritual aspect of dying?

Answer 27

- More than just religion - High subjective - Very personal - Varies from person-to-person, culture-to-culture, society-to-society - How we relate ourselves to each other and the things around us, what motivates us: - Self identity - Meaning - Relationships - Reflection - Motivation - Less requirement for analgesics and when drugs needed, they work better - The power of this phenomenon can be modelled on MRI with ACC - Religious conviction - reduced reactivity in the anterior cingulate cortex (ACC), a cortical system that is involved in the experience of anxiety and is important for self-regulation

Question 28

How do you assess spiritual need?

Answer 28

- ‘It cannot be assumed that all patients have spiritual needs at all times, and that when they do, that they always want to need to share these with health professionals.’ - Taking a Hx: - H.O.P.E - What sources of Hope, strength, comfort, meaning, peace, love and connection does the patient have? - What role does Organised religion play in the patient’s life? - What is the patient’s Personal spirituality and practices? - What will be the Effects of these factors on the patient’s medical care and end of life decisions?

Question 29

What is the problem with breathlessness?

Answer 29

a. Ranked in top 10 Sx of advanced ca b. 75% in lung cancer c. Independent predictor of survival d. Hard to Rx

Question 30

What is the physical treatment of SOB?

Answer 30

- Very disabling, and very hard to treat. - Oxygen is widely given, but it not effective for cancer patients. - No relationship to oxygen saturations. - Fixing O2 sats may not fix disability.

Question 31

What is the psychological basis for SOB?

Answer 31

i) Neuropsychological: - Limbic/paralimbic activation occurs in air hunger - Also activated by awareness of other homeostatic threats, including pain, thirst and hunger - Such threats demand behavioural action, motivated by emotion ii) Psychological: - Experience of distress, fatigue, air hunger - Spiral - the more SOB, the less exercise, the worse - Breathless people get scared they will die - this very rarely happens! iii) Psychosocial: - Distress is a contagious disease - Families/carers can reinforce symptoms - Same can happen to healthcare professionals - will have effects on Rx effectiveness! - Think about things cooly, then decide what to do. - Absence of normalising social environment further reinforces this - ?Improving social support can also reduce breathlessness (or other symptoms?)

Question 32

What are the 5 dimensions of spiritual care?

Answer 32

1. Presence – active, empathic listening 2. Prayer – a broad spectrum of spiritual practice 3. Ritual – including spiritual ceremonies, life cycle transition events, etc 4. Learning texts – not just the Bible/Koran/Torah/Book of Buddah, but also prose, poetry, drama (‘Shakespeare as a Prompter’) 5. Advocacy – including facilitation of communication with staff

Question 33

What is the most important in the final days?

Answer 33

1. Be kept clean 2. Named decision maker 3. Have a nurse with whom one feels comfortable 4. Know what to expect about one’s physical condition 5. Have someone who will listen 6. Maintain one’s dignity 7. Trust one’s physician 8. Have financial affairs in order 9. Be free of pain 10. Maintain sense of humour

Question 34

What symptoms occur near death?

Answer 34

1. Increasing fatigue 2. Negligible nutritional intake - no appetite 3. Altered fluid requirements 4. Changes in breathing 5. Noisy breathing a. This may worry families - reassure them that the patient is getting the best possible care! 6. ?Reducing levels of pain/distress 7. No evidence for effectiveness of CPR

Question 35

How do you know if the patient will die soon?

Answer 35

● Prognostication difficulties in palliative care in immediate and short-medium terms: o Karnofsky Index (Yates et al, 1980) o Barthel Index (Bennett & Ryall, 2000) o PiPS (Gwilliam et al, 2011) o Morita (1998): 4 signs of dying ● Practical question from relatives: “should we stay tonight?” o Oscar Hospice Cat (Dosa, 2007) Tachypnoea (RR>28) seems to be a reasonably specific indicator of rapidly approaching death ● Limited by sensitivity ● Difference between positive and negative screens is statistically significant Tachycardia (pulse>120) is less sensitive and specific ● Difference between positive and negative screens is not statistically significant Combination tool is limited by poor sensitivity

Question 36

What are the P's of palliative care?

Answer 36

1) the Patient 2) Pain 3) Poo (usu constipation) 4) Puke (nausea and vomiting) 5) Preathlessness 6) Psychology (e.g. anxiety, depression) 7) People (e.g. families, carers, friends, support-network) 8) Practicalities - keeping someone at home 9) Pennies 10) Peace & Prayers 11) Planning (of care, and of death) 12) Positives