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.
What tends to happen in the final days of life?
Increasing fatigue- sleep increases, more deep, comatose
NeglIgible nutritional intake- no appetite.
Altered fluid requirements- less fluid needed
Changes in breathing.
Noisy breathing.
?Reducing levels of pain/distress.
No evidence for effectiveness of CPR.
Epidemiology of dying
Common chronic illness that causes death?
500000 people die a year 2/3- over 75 years Ageing population People dying older Rise in female deaths More men dying overall each year than females Majority after period of chronic illness
Common chronic illness that causes death CVD Resp Neuro Dementia Stroke Cancer
What is the pattern of growth of cancer cells?
Exponential
What are common physical symptoms of cancer?
Fatigue
Pain
Breathlessness- anaemia, lymphangitis, lung cancer
Anorexia
Cough
Constipation
Nausea
Insomnia
Anxiety
Depression
How do opioids work?
How effective are they?
What side effects do they cause? Why and how can you get around this?
Mu receptors
Good response 95% of time for cancer pain
Allergic - rare
Constipation- lots of mu receptors in GI
Can give transdermal eg fentanyl instead of oral morphine to combat this
Nausea- give anti emetics
What can be done to improve patient’s quality of life in terms of psycho-social and spiritual aspects?
Psychological- CBT, counselling, relaxation
Complementary therapies acupuncture
Spiritual/religious beliefs- understand patient’s belief system about death, pain etc.
Physio + OT
Social service
If patients know they are dying, is there any evidence they will die quicker/give up hope?
No- hope just changes
Breathlessness in palliative patients
Most frequent symptoms in lung cancer- 75% of patients
Perception of breathlessness complicated-lots of neural pathways- limbic/ paralimbic + fight or flight activation can cause air hunger
More than just oxygen sats- sometimes sats can be high but pt still v breathless
Difficult to treat
Independent predictor of survival
Often due to thick diffusion surface in lungs b/c of cancer tissue- so increasing oxygen given won’t help
Blowing air onto face/body - has been shown to help
Control anxiety
How to predict immediate/short term prognosis- when will patient die ?
Blood tests- high potassium- high calcium, low albumin, low sodium
- especially bad if rapid change
Rate of deterioration will be same as it has been previously
Indexes can be used: Karnofksy Index Barthel Index PiPS Morita- Four signs of dying
