Discussing bad news in patients with progressive disease in the acute setting

1. Discussing bad news in patients with progressive disease in the acute setting Ursula McMahon – Macmillan Acute Oncology & Cancer of Unknown Primary

2. Session Content • Oncology in Acute Hospitals – • What is role Acute Oncology – • Acute Oncology -Wigan Model • What isn’t Acute Oncology • Breaking Bad News • Case Senario

3. Oncology in an Acute Setting

4. Acute Oncology Service • The Acute Oncology Service (AOS) was established at WWL in June 2013 • The service seeks to bring together expertise from Emergency Medicine, Acute Medicine and Oncology to better meet the needs of acutely unwell cancer patients

5. Acute Oncology - What is it? • Prompt review of patients presenting with complications of treatment/disease • Neutropenic sepsis • MSCC • Providing advice and sign posting to relevant management guidelines (where necessary) • Review of patients in whom a first diagnosis of cancer is made in the emergency setting. • Information provision of patients’ cancer treatment

6. Acute Oncology Team- Wigan Model • Consists of • 3 Clinical Nurse Specialists • 2 Medical Oncologists (visiting consultants from The Christie) providing a session per day • 1 Senior Specialty Doctor • 1 MDT coordinator • 9am to 5 pm • Monday to Friday

7. What isn’t Acute Oncology • AOS does not replace existing diagnostic pathways for patients with suspected cancer • AOS will not necessarily review patients just because they have cancer • We may not be able to provide specific disease management plans for everyone – need to involve parent team

8. Breaking Bad News

9. Delivering Bad News S- SETTING UP the interview P-Assessing the patient’s PERCEPTION I- Obtaining the patients INVITATION K- Giving KNOWLEDGE and information to patient E- Addressing the patients Emotion and Empathic Responses S- STATEGY and SUMMARY Baile et al 200 Spikes Six Step Model

10. Delivering Bad News (2) C- Circumstances: Outline setting and why the patient is there P- Previous clinical state: summarise all aspects of prior health for this event including the extent of and outlook for the cancer, any co-morbidities, and what the patient was and was not able to do (functional status). Check the patients understand and whether this concurs with the picture. A- Acute illness: describe sequence of events and known people and teams involved in care so far. Check the patients and carers thoughts on the mail problems and what this could mean. A-Assessment: Current status of vital signs and function of organs. Be prise and use specific available data. T- Treatment: recent and current interventions and treatment for acute illness, the expected benefits and likely outcome. The situation may be grave, and it is helpful to indicate there has been liaison with the oncologist. P- Plan: describe immediate options and what is proposed, including referral to other teams. This may mean escalation ( to intensive care) or de-escalation with focus on symptomatic care. AT EACH STEP CHECK PATIENTS UNDERSATANDING OF INFROMATION GIVEN, THEIR REACTION AND IMMEDIATE CONCERNS AND ANY QUESTIONS. Cancer patients in Crisis responding to urgent needs RCP 2012 Communicating Significant News in complex situations

11. Case Senario • 40 f • Originally seen in WWL but Gynaecology Team. Discussed in MDT 12/4/19 and • PV bleeding • Large irregular cervical mass • Diagnosis: FIGO Stage IVA Cervical Ca • Outcome: Systemic anti- cancer therapy. • PET scan 24/4/19- • Small lung nodule “could represent metastatic disease but peripheral distribution is unusual” • Bone lesions • Oncology OPD clinic -2/5/19- • advanced disease in pelvis with lymph node involvement. Advise of uncertain areas in both lung and bone. • Planned for 25 treatments of radiotherapy with weekly Cisplatin. • Due to commence week c/o 20 May

12. Case Scenario (2) • Admitted to WWL 15/5 with SOB and Low Saturation • Referred to and reviewed by AOT on 15/5. Plan was for CTPA – no active ongoing input from AOT indicated • Re-referred to AOT 17/5 by ward team as CTPA evidence of lung nodules suggestive of progressive/ metastatic disease. • AONS requested the patient be made aware of results and would attend ward to review. Ward team give patient ‘Warning shot’ about suspicious areas. • Pt told Ward team was she was aware of areas already and her oncologist were not sure what they were. • AONS attended ward but patient had left. • Oncologist contacted by AONS – evidence of progressive disease evident on CTPA which confirmed Metastatic nature disease thus changing treatment intent and management. • Discussion of how managed.

13. Delivering Bad News - Assess patients understanding Give a warning shot Present the bad news using words the patient will understand Be quite and listen Provide additional information in layers as requested by the patients or family Follow up: this is the beginning of a journey for the patient. 6 Step Approach