EOL care Closing the Gap 2b

LEARNING OUTCOMES Breaking bad news Clarifying what the patient knows Initiating appropriate palliative care measures: district nurse referral, Macmillan nurse referral, symptom control, Gold standards framework. Symptom control as disease progresses. How to approach difficult/sensitive issues; example here is DNAR form. Dealing with concerns and expectations of patients and family members. Example here: husband’s concerns re weight loss, appetite.

Additional case scenario 72 year old lady admitted to hospital by your GP colleague 3 weeks ago, when she presented with acute shortness of breath, The GP notes from the time suggest a diagnosis of either pneumonia/pleural effusion. Today she requests a home visit, having been discharged from hospital 2 days before. The visit request says: “left leg pain.” The discharge letter from the hospital states: “Malignant pleural effusion: treated with chest drain. CT abdomen and pelvis; suspicious ovarian mass, likely malignant. No obvious metastasis in abdomen or pelvis. Referred to gynaecology oncology as OP”. It is not clear from the discharge letter, how much the patient was told, if anything, about the diagnosis/scan findings. How would you approach the findings on the hospital letter when you visit?

Part 2 When you visit, she tells you that the leg pain started in hospital. She had a scan to look for a blood clot, which was normal. Clinically there is no sign of a DVT when you examine the leg. After discussion, Mrs P knows that she has fluid on her lung and possible ovarian cancer. She is fairly pragmatic about the news and hopeful that the gynaecologist can offer treatment, as the cancer hasn’t spread outside of the ovary. How would you respond to this?

Part 3 Some weeks later, you visit again. Mrs P was re-admitted to hospital with abdominal ascites, requiring drainage. She has been told that she cannot have any curative treatment for her condition. Mrs P’s main symptoms are nausea. She is eating very little and her husband wants to know what can be done to improve her appetite and help with weight gain. As you are just about to leave for the visit, the district nurse stops you with the new multi-agency DNAR form, created by the local palliative care team. She asks if you can discuss this with Mrs P and complete the form during your visit.