Advancing disease

Published on 09/04/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 09/04/2015

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22 Advancing disease

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.

Assessment and holistic care

Complete the family assessment tool introduced in Appendix 2. This will assist you to gather information about Simon and the other family members so you can start to make an assessment as to how they are coping with the changing situation.

Make a list of what you think the main concerns and worries might be for:

Michelle’s parents.

What do you think their current understanding of Michelle’s illness is?

As the nurse looking after Michelle, consider what your main concerns would be.

Make a list of the other information that is needed to make a holistic assessment of Michelle.

NMC Domain 1: 1.1; 1.2; 1.4

NMC Domain 2: 2.1; 2.3; 2.4

NMC Domain 3: 3.1; 3.3; 3.7; 3.9

NMC Domain 4: 4.3

Further reading

Maher D., Hemming L. Understanding patient and family: holistic assessment and palliative care. Br. J. Community Nurs.. 2005;10(7):318–322.

Taylor E. Supporting families of dying patients: communication skills. End of Life Care. 2007;1(3):8–15.

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.

Breaking bad/significant news

This is significantly bad news for both Michelle and Simon and consideration is needed of how this news will be given. Access the East Midlands Cancer Network ‘Guidelines for communicating bad news’:

http://www.eastmidlandscancernetwork.nhs.uk/Library/BreakingBadNewsGuidelines.pdf (accessed November 2011).

You will find an 11-step flowchart on page 32. For each of the 11 steps, write down how you can prepare to give this significant news to Michelle and Simon. Who might be the best person to give this news? If you were giving the news, consider how you would prepare.

NMC Domain 1: 1.1; 1.2

NMC Domain 2: 2.1; 2.2; 2.4; 2.5

NMC Domain 3: 3.7; 3.8

NMC Domain 4.4; 4.6

Further reading

Fujimorl M., Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review. J. Clin. Oncol.. 2009;39(4):201–216.

Girgis A., Sanson-Fisher R., Schofield M. Is there consensus between breast cancer patients and providers on guidelines for breaking bad news? Behav. Med. 1999;25(2):69–77.

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.

Back pain

Advancing disease is the most likely reason for Michelle’s back pain. Refer to Section 2 and read again about malignant spinal cord compression.

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