Case update

It is 8 months since Michelle received her last treatment and was discharged from the oncology ward. After resting for 2 months, Michelle returned to her role as a doctors’ receptionist for 5 hours per week. Returning to work is important to Michelle, especially being able to get dressed and put on her make-up. Her hair has grown back and Michelle has had it restyled – her family and friends think it looks ‘fab’. Michelle has felt continuously tired and has put this down to returning to work and ‘dealing with the diagnosis’. She has visited her GP several times who has monitored her recovery.

Michelle has been feeling increasingly unwell over the last 4 weeks and is getting quite distressed at home. This is mainly due to nausea and vomiting, tiredness and not feeling rested after sleep, with increasing abdominal pain, back pain and reduced mobility. Michelle has been in bed for 6 days and feels too unwell for Simon to take her in the car to visit her GP, so he does a home visit. She feels too tired to help with the children’s homework and is very tearful.

Her GP recognises the deterioration in Michelle’s condition and arranges for her to be admitted to the local medical admission unit for urgent assessment and management of her symptoms. He starts her on morphine 10   mg as required to help her feel more comfortable while waiting for the admission. Michelle appears relieved at this decision to be admitted and is taken to hospital by ambulance on that same day. The only other medication Michelle has been taking is a hormone relating to her breast cancer treatment.

Simon is very tired and feeling frustrated that he doesn’t seem to be able to help her distress. The children are getting to school late and Simon has not been to work for the last week.

Points to consider

Information collected on admission can be useful when planning a complex discharge, and completing the admission assessment documentation as fully as possible provides a lot of core information. For example, Michelle had reduced mobility before the admission so it is important to find out where the bathroom is at home. If access to a toilet has been a problem before admission, it is essential this is given consideration for the discharge planning process. It is also important to find out what medications have been prescribed and not to assume they have been taken by Michelle. Ensure all this information is clearly documented so any person from the care team helping to arrange discharge has the correct information.

Case update

A magnetic resonance imaging (MRI) scan and blood tests have shown that Michelle’s disease has progressed and the abdominal pain is from spinal metastases. Her blood calcium is raised, giving the diagnosis of hypercalcaemia. Michelle and Simon are now given this difficult news.

Points to consider

Receiving news about a change in condition can be as devastating as receiving news at the time of the original cancer diagnosis. Where possible, ensure that all members of the care team are aware the news is being given so they can offer support, not only to the patient and their family but also to those in the care team who are giving the information.

We now consider what might be causing each of the symptoms Michelle is experiencing.

Points to consider

Malignant spinal cord compression is a significant and distressing symptom since it can drastically impact on a patient’s activities of living as well as signify a serious advance of the cancer. Patients and their families need much support and care at this time.

Points to consider

A patient who is not vomiting can be very distressed from unresolved nausea. It is important to ask how the patient is feeling and not to make the assumption that no vomiting means no nausea.

Points to consider

Don’t assume that patients and their relatives know the link between opioids and constipation. Many patients need to have the link clearly explained to ensure that a laxative is taken regularly. Remember that prevention of constipation is much better for a patient than managing discomfort and pain associated with constipation. Also, when assessing a patient with advancing metastatic disease who has constipation, always consider the possibility of a spinal cord compression.

Points to consider

It is important to know what might be the cause of distress. For many people, it is having to cope with physical symptoms; for others, it will be worry about financial issues or other members of the family. Worry beyond the self is often referred to as existential suffering. Every patient is different and gathering information from a wide range of sources will help the care team to make an informed assessment as to what might be causing the distress. Finding out how a person has managed a previously distressing situation can help in understanding how they respond to a current crisis. Previous experiences, even though the patient may have had a different diagnosis and symptoms, can be important when considering how to provide best care in distressing situations.

Points to consider

As symptoms become more complex and distressing, keeping a holistic focus of Michelle is essential in order to meet her needs and help to manage symptoms. Keeping Michelle central to the assessment is essential and the distress thermometer (see page 35) can help with this. Sometimes the complexity of symptoms a patient experiences can feel overwhelming, and separating out the problems, family needs and care interventions in this way can help focus on the many aspects that are often forgotten.

Case update

Michelle is started on dexamethasone for the spinal cord compression and a normal saline infusion to prepare her for treatment for the hypercalcaemia. After 3 days, Michelle continues to feel tired, though the vomiting is now settled and Michelle is enjoying small amounts of food. She particularity looks forward to the children visiting after school. Michelle is no longer constipated and continues to take regular laxatives. Michelle has been referred to the hospital Macmillan team for specialist management advice and support. The assessment unit team are now considering discharging Michelle home in the next few days.

Points to consider

In the Chapter 16, we explored the importance of knowing what the patient’s priorities of care are and giving them choices about their care. When planning the discharge of a person with advancing disease, it is important to keep their needs central to the discharge process. It is important to consider the wider team working and ensure the discharge is planned in a safe and appropriate way. The above article focuses on the discharge of a woman with advanced multiple sclerosis, giving you ideas of how skills and knowledge can be transferred across disease pathways.

Case update

Michelle has told nursing staff that she is frightened at the thought of going home but doesn’t want to upset Simon and the children who seem so excited. Staff have noticed her requesting analgesia more frequently for her abdominal pain and sleeping through the children’s tea time visits. Simon has spoken independently to the care team about his anxiety at the plan for Michelle to go home.

Points to consider

Careful planning at this stage is vital and Simon needs to be kept central to the plans. Consideration needs to be given to how he is feeling about the proposed discharge and if he recognises how unwell Michelle now is. Sometimes a patient being discharged can be mistaken by family members as the person being ‘well enough to go home’.

The next chapter explores the care Michelle and her family will need as she moves into the last days of her life.