Mrs Joan Smyth is a 74-year-old woman who was diagnosed and treated for primary breast cancer at age 69. She has recurrence of the disease with liver, brain and bone metastases. She recently completed three courses of chemotherapy and radiotherapy to her brain. Joan is aware of the advanced stage of her cancer condition. She is feeling increasingly weak by the day, sleeping most of the time and declining to eat and drink. Joan blames the chemotherapy for feeling like this.
Joan’s husband Bill has end stage heart failure. They have two adult children and seven grandchildren. Their son Mick lives abroad and he is not aware of his mother’s deterioration. Their eldest daughter Elizabeth has temporarily moved back home with her three young children to care for her ill parents.
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1. What is the likely cause of Joan’s symptoms?
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Correct answer:
There are many possible causes including infection, fatigue, effects of treatments and electrolyte imbalance. However, as Joan has profound progressive weakness, is almost bed-bound, and has indifference to food and fluid; she is likely to have begun transitioning to an actively dying phase (see Chapter 50). Changing goals of care should be negotiated and communicated to all within the multi-disciplinary team. This includes a ‘do not resuscitate order’.
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2.It is agreed that Joan is dying. What medication considerations need to be made?
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Correct answer:
The following considerations should be made:
- Review all medications and discontinue medications that are deemed unnecessary.
- Continue medications for common symptoms including pain, agitation, respiratory tract secretions, dyspnoea, nausea and vomiting.
- Ensure the appropriate route for medications is prescribed. For example, if Joan is experiencing difficulties swallowing, essential oral medications should be converted to the subcutaneous route.
- Symptoms must be assessed daily and medications adjusted accordingly.
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3. What withdrawal of treatments and procedures may be considered to limit patient interruptions and discomfort?
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Discontinuing vital sign assessments, pulse oximetry, intravenous hydration, blood transfusions and blood sampling should be considered. The decision should be documented and communicated to all.
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4. What is a syringe pump?
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Correct answer:
A syringe pump is an effective method of drug administration to manage common symptoms. It is used when the oral route is deemed unsuitable mainly due to dysphagia secondary to weakness/decreased consciousness, or to manage intractable vomiting.
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5. What are the main advantages of using a syringe pump?
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A syringe pump delivers constant therapeutic drug levels over accurate infusion times. It does not impede mobility. It reduces the need for regular injections. Multiple symptoms may be managed as more than one drug may be used together, once they are compatible.
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6. Why might a family meeting required?
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Correct answer:
Sensitive, empathetic and open communication should be maintained with Joan and her family throughout her disease process. Once the dying phase is diagnosed, a family meeting should be facilitated by members of the multi-disciplinary team to:
- Provide a medical update informing them that the signs and symptoms indicate that Joan is actively dying
- Review the changing goals of care and the comfort measures to be initiated.
- Explain what Joan and family may experience or witness during the terminal stage (last days and hours of life) and at the time of death.
- Check their understanding and answer questions.
- Reassure them that on-going information will be provided.
- Give the family time to express their concerns and fears.
- Offer family support information, and contact with other team members such as social work and chaplaincy as appropriate .
- Demonstrate a shared approach to care by valuing and respecting family members’ participation in care.
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7. What specific family issues may need to be addressed with Elizabeth?
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Correct answer:
Check if Mick has been informed of Joan’s condition and advise that he should be afforded the opportunity to travel home if he so wishes. If it is helpful, offer to arrange for a member of the team to update Mick by phone or other communication devices. Check Elizabeth’s own support needs, remembering she is also caring for her ill father and young children. To help the grandchildren prepare for Joan’s death, provide Elizabeth with material about age appropriate understanding of serious illness and death. Referral to social work/psychosocial support services may be required. Encourage Elizabeth to seek support from extended family and friends at this time. Regardless of the setting, endeavour to offer Elizabeth and her family the privacy and space required to present with Joan in her final days.
