The dying cancer patient

Question 1

What are the 4 causes of cancer causing symptoms?

Answer 1

Primary tumour- where the cancer is.
Distant metastases- paraneoplastic syndromes.
Body’s response to primary tumour and metastases.
Treatment given for any of the above.

Question 2

Pathophysiology of the systemic inflammatory response to cancer.

Answer 2

Neuroendocrine: fever, somnolence, anorexia; raised cortisol and catecholamines.
Haematopoietic: anaemia, leucocytosis, thrombocytosis.
Metabolic: decreased muscle, -ve nitrogen balance; increased lipolysis; cachexia.
Hepatic: increased blood flow; increased acute phase proteins.

Question 3

Why do cancers cause symptoms?

Answer 3

Other complications from organ dysfunction, including SIADH, hypoadrenalism, GIT dysfunction.

Question 4

What is the pathophysiology of cancer symptoms?

Answer 4

Similarity to infection disease: exponential growth of tumour cells.
Immune/inflammatory response to cancer.
Biochemical changes: falling albumin, falling creatinine, anaemia.

Question 5

What is the epidemiology of dying?

Answer 5

Approximately 500,000 people die in England each year.
2/3 deaths n people >75 years.
Rise in female, as opposed to male deaths, but more men still dying each year.
Majority follow period of chronic illness: cardiovascular disease, cancer, chronic respiratory disease, stroke, neurological disease, dementia.

Question 6

How good are doctors at predicting the prognoses of cancer patients? Do we tend to overestimate or underestimate prognosis?

Answer 6

Tend to overestimate, too optimistic.

Question 7

What are the 4 domains of patient care in assessing the dying patient?

Answer 7

Physical
Psychological
Spiritual
Social

Question 8

What are the ‘P’s of palliative medicine?

Answer 8

Pain
Poo (usu constipation)
Puke (nausea and vomiting)
Preathlessness
Psychology (e.g. anxiety and depression)
People
Practicalities
Pennies
Peace
Prayers
Planning (of care, and of death)
Positives

Question 9

What are the 3 main questions to answer in assessing physical symptoms of a cancer patient?

Answer 9

What is causing this symptom?
How is it affecting this person?
What, if anything, should I do about it?

Question 10

What is pain?

Answer 10

Subjective. Pain is what the patient tells you it is.
Causes of pain and suffering are multimodal, integrative and dynamic.
Treatment depends on a full assessment, multimodal approaches with pharmacological, physical and psychological therapies, which are dynamic and responsive to change.
80-90% of all pains could be palliated by relatively simple means.
SOCRATES.

Question 11

How do you treat pain? WHO analgesic ladder.

Answer 11

Step 1: non-opioid, ±adjuvant.
– pain persists or increases –
Step 2: opioid for mild-moderate pain, +non-opioid, ±adjuvant.
– pain persists or increases –
Step 3: opioid for moderate-severe pain, +non-opioid, ±adjuvant.

Question 12

What is fatigue as a symptom?

Answer 12

The most tired and exhausted you’ve ever felt.
Common symptom >80% advanced cancer patients.
Common in all advanced illness.
Not reversible with sleep.
Limits functional ability.
Treatment: graded physical exercise, no drugs have any evidence for long term benefit, most short term seems sleep restoration.

Question 13

Anorexia/cachexia as a symptom of the dying patient.

Answer 13

Advanced disease driven cachexia.
Not reversible with nutrition- no place fo TPN or NG feed.
Altered cytokine and metabolic state.
Short term benefit: dexamethasone, megestrol, venleflaxine; no evidence for muscle gain, only fluid retention; exception may be androgens.

Question 14

What are the stages of change as a psychological aspect of dying?

Answer 14

Pre-contemplation/denial.
Contemplation/ambivalence.
Determination, preparation.
Action.
Maintenance- living it.
Relapse/recycle.

Question 15

Anxiety and depression and psychological aspects of dying.

Answer 15

Higher rates of depression and anxiety in all chronic illnesses.
Depression and anxiety worsen quality of life and limit treatment efficacy.
Evidence that treating depression/anxiety improves chronic illness QOL/symptoms.
Also improving QOL improves depressive/anxiety symptoms.
Under-recognised, under-treated.

Question 16

What do we mean by spirituality in the dying patient?

Answer 16

More than just religion- a feeling that is highly subjective, usually very personal, and varies from person-to-person, culture-to-culture, society-to-society.
Self identity, meaning, relationships, reflection, motivation.
Religious conviction is marked by reduced reactivity in the anterior cingulate cortex, a cortical system involved in the experience of anxiety and is important for self-regulation.

Question 17

What do people rank as most important in their final days?

Answer 17

Be kept clean.
Named decision maker.
Have a nurse with whom one feels comfortable.
Know what to expect about one's physical condition.
Have someone who will listen.
Maintain one's dignity.
Trust one's physician.
Have financial affairs in order.
Be free of pain.
Maintain sense of humour.

Question 18

What tends to happen in the final days of life?

Answer 18

Increasing fatigue.
NeglIgible nutritional intake- no appetite.
Altered fluid requirements. 
Changes in breathing.
Noisy breathing.
?Reducing levels of pain/distress.
No evidence for effectiveness of CPR.