Download Audit Meeting HPB - The Family Doctor Association

Recognising illness in the
Terminal Stage
Mr Aali Sheen
10th October 2015
Who am I?
Consultant General Surgeon
Hepatopancreatobiliary specialist
Abdominal wall and Hernia
Medical school 1993
Trained in London, Leeds and Manchester
Appointed Consultant in 2005
Undertaken 450 Liver/GB; 101 Pancreas
resections for cancer
Introduction
Diagnosis of cancer is not always easy
Cardinal signs
Soft signs
Can always be missed
Cased based scenarios
– Straightforward
– More difficult in interpretation
Early symptoms
Generally feeling unwell
‘Not Right”
Haven’t been the same
Going on for a few months
Occasional tummy pain but nothing
serious
But I was eating fine up until last week
Cardinal symptoms
Weight loss
Abdominal discomfort
Poor appetite
Altered bowel habit
PR bleeding
Dysphagia
Odynophagia
Haemoptysis
Signs
Increasing age
Recent change in lifestyle
Thin (not always)
Cachectic
Jaundiced
Abdominal distension
Lump – SJ nodule
How can we tell?
Case 1
69 year old man
Likes his drink
Noted tummy swelling
Feels otherwise ok
Eating plenty
Thought he should come and see you?
Tests??
Ultrasound?
Routine serum investigations
Cancer pathway
Immediate referral to Specialist and
Cancer MDT
Tumour markers – can be undertaken in
hospital
Hepatoma
History predicts problem
Diagnosis often late
Cirrhosis
Options for cure are limited
– Surgery if Childs A
– TACE
– Ablation
– Chemotherapy
Case 2
35 year old patient mother of three
Feels awful
Jaundiced !
Bilirubin – 275
Admission to Hospital – don’t take no for
an answer – Call the Consultant
Investigations
Relief of Jaundice failed with ERCP
Tight distal bile duct stricture ? Stones
Percutaneous drain inserted – could not
bypass stricture – is this malignant?
Patient deteriorating
Died 30 after admission
Diagnosis
Malignant cholangiocarcinoma – on a
background of choledochal cysts
Poor overall prognosis
Take home message
Very high Bilirubin!
It’s ok for a transient rise but not to a very
high level
Case 3
55 year old lady with UC complained of a
low Hb
Investigated with colonoscopy – no tumour
Gastroscopy normal
Bloods show a mild anaemia
No obvious other abnormalities
What next??
Blood film
Bone marrow
Abdominal imaging
Ultrasound
– Dilated ducts on the left lobe only
– Normal LFTs
CAT scan ?
X-sectional imaging showed possible PSC
Segmental cholangiocarcinoma is a worry
Needs surgery
Chemotherapy not ideal for this cancer
Surgery undertaken – patient well
What to look out for?
Unexplained weight loss
Bleeding – Vomit/PR/PV
Persistent heartburn or indigestion
Altered bowel habit
Jaundice
Haempotysis
Breast Lump
Abnormal persistent lump
Terminal Cancer
Review care needs and goals of care with resident
(if able), family and GP
Implement palliative care plan or pathway
Ensure care given is in line with previous direction
from the resident, if they are now unable to give
direction
Manage symptoms appropriately
Withdraw treatments, activities, medication that are
no longer appropriate or benefiting the resident
Provide counselling and support, to the resident,
family and staff.
Three triggers !
The Surprise Question "Would you be
surprised if this patient were to die in the
next few months, weeks, days'?"
General indicators of decline deterioration, increasing need or choice for
no further active care
Specific clinical indicators related to
certain conditions (unresolving jaundice).
Guidance
Three case scenarios
69 year old woman with terminal cancer
84 year old with deteriorating medical
condition
91 year old lady with chronic condition
GSF guidance
A – Blue
– Diagnosis – Stable with a year + prognosis
B – Green
– Unstable, Advanced disease
C – Yellow
– Deteriorating, weeks prognosis
D – Red
– Terminal care, final days
NAVY After care
Change in Patient’s status
Weight loss (more than 10% of body
weight in last 6 months); BMI below 18
Serum albumin less than 25g/l
General physical decline; dependent in
ADL’s, bed / chair fast
Multiple diseases impacting on wellbeing
Increased frequency of admissions to
acute care.
End of life
Prepare family for passing away
Unexpected when it finally happens
Painful for all involved
Try not to expect them to know to much
information – as all the information they
have received may not have ‘got through’
Best to let them ask any questions ?
Summary
High index of suspicion
Severe abnormality in blood tests should
raise alarm bells
Increasing age is important but younger
patients usually present late with
advanced disease - If in doubt please refer
on
Triggers
Preparation for death is never easy
Useful Links
NICE
– http://www.nice.org.uk/guidance/cg27/chapter/guidan
ce
Macmillan
– http://www.macmillan.org.uk/information-andsupport/diagnosing/how-cancers-arediagnosed/signs-and-symptoms/signs-andsymptoms.html
Cancer research UK
– http://www.cancerresearchuk.org/aboutcancer/cancer-symptoms
Thanks to HCA
Clare Evans
www.manchestergeneralsurgery.co.uk
www.manchesterherniaclinic.com