The dying cancer patient Flashcards
What are the 4 causes of cancer causing symptoms?
Primary tumour- where the cancer is.
Distant metastases- paraneoplastic syndromes- hyponatremia, hypercalcaemia [PTHrp]
Body’s response to primary tumour and metastases.
Treatment given for any of the above.
How does the systemic inflammatory response to cancer affect the body exactly and what symptoms and signs does it produce?
Neuroendocrine:
fever [often first presentation], 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.
Why do cancers cause symptoms?
Systemic inflammatory response
Complications from tumours invading and causing organ dysfunction, including SIADH, hypoadrenalism, GIT dysfunction.
How good are doctors at predicting the prognoses of cancer patients? Do we tend to overestimate or underestimate prognosis?
Tend to overestimate, too optimistic.
What are the 4 domains of patient care in assessing the dying patient?
Physical
Psychological
Spiritual
Social
What are the ‘P’s of palliative medicine?
[*not in lecture]
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
What are the 3 main questions to answer in assessing physical symptoms of a cancer patient?
What is causing this symptom?
How is it affecting this person?
What, if anything, should I do about it?
Don’t put all symptoms down to cancer- SOCRATES each symptom
What is pain?
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.
How do you treat pain? WHO analgesic ladder.
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.
What is fatigue as a symptom?
How to treat it?
The most tired and exhausted you’ve ever felt- as if physically weighed down
Not reversible with sleep.
Limits functional ability.
Common symptom >80% advanced cancer patients.
Common in all advanced illness.
Treatment: graded physical exercise, no drugs have any evidence for long term benefit, most short term seems sleep restoration.
Anorexia/cachexia as a symptom of the dying patient.
What is it?
How do you treat it?
Anorexia= loss of appetite Cachexia= loss of body mass
Pre cachexia- if caught early- can reverse
Altered cytokine and metabolic state.
Not reversible with nutrition-TPN or NG feed.
Short term benefit: dexamethasone, megestrol, venlafaxine, mirtazapine.
No evidence for muscle gain, only fluid retention;
Exception may be androgens/steroid- symptom relief.
What are the stages of change as a psychological aspect of dying?
[*not in lecture]
Pre-contemplation Contemplation/ambivalence. Determination, preparation. Action. Maintenance- living it. Relapse/recycle.
Anxiety and depression and psychological aspects of dying.
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
Under-recognised, under-treated.
Differentiate between normal reactionary sadness + depression= prolonged, guilt, worthlessness
What do we mean by spirituality in the dying patient?
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.
What do people rank as most important in their final days?
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.
