Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Spinal Cord Compression Guidelines October 2004 SPINAL CORD COMPRESSION GUIDELINES Section 1 : Signs and Symptoms Section 2 : Initial Treatment and Management Section 3 : Treatment and Management in inpatient unit Section 4 : Investigation Pathway Section 5 : Treatment Pathway following diagnosis of Spinal Cord Compression Section 6 : Rehabilitation Pathway Section 7 : Nursing Care Section 8 : Patient Information Section 9 : Continuing Care for patients who are paralysed Section 10 : Contributors 1 SECTION 1: SIGNS AND SYMPTOMS OF SPINAL CORD COMPRESSION Key Point The outcome of Spinal Cord Compression (SCC) is related to early treatment. While diagnosis may be obvious in late disease, initial symptoms may be vague. A high index if suspicious must be maintained. 1.1 Causes of Spinal Cord Compression (SCC) SCC occurs when pressure on the cord leads to neurological dysfunction. Areas of spine affected are thoracic (70%), lumbosacral (20%) and cervical (10%). In most cases onset is gradual. Occasionally however onset is acute. Pressure on the cord commonly results from local tumour spread either posteriorly from a vertebral body or by a paravertebral tumour invading via the intervertebral foramen. Metastatic involvement of vertebral bodies may lead to bone weakening and subsequent fracture or collapse. Bone fragments may be displaced posteriorly and impinge on the cord. This is associated with sudden onset of symptoms. 1.2 Signs and Symptoms Signs and symptoms depend on the area of cord affected. As onset is gradual initial symptoms maybe vague and diagnosis may be missed. Common symptoms in the thoracic area are:Back pain (typically radicular) Sensory disturbance in lower limbs Urinary disturbance Leg weakness Signs are those of bilateral upper motor nerve lesion in the legs and a sensory level may be detected. Cervical cord involvement may be suspected if there are neurological symptoms or signs in the arms. In the lumbar spine compression may be below the level of the cord affecting the cauda equina. This leads to nerve root pain in back and legs. Urinary disturbance may be a feature. Signs are of a lower motor neurone lesion in the legs. There may be signs of nerve root irritation shown by limited straight leg raising. 2 1.3 Practical Points SCC should be suspected if there is: A change in the character or severity of back pain, worse on lying down. Alteration in sensation Urinary hesitancy Diminished power of erection in men Feelings of weakness or inco-ordination Increasing radicular pain, worse on coughing, especially if affecting upper body Pain worse on lying down. Pain arising from thoracic area. If the patient experiences two or more of the symptoms below it is probable that spinal cord compression will exist: Rapidly escalating pain which is difficult to control even with increasing dose of opioids. Acute sudden sensory and motor weakness defit Acute bladder and sphincter dysfunction Night pain/pain on lying down History of primary tumour. References/Bibliography Hillier R., Wee B (1997) Palliative Management of Spinal Cord Compression European Journal of Palliative Care 4(6) 189-192. Spence R.A.J. and Johnston P.G. (eds) (2001) Oncology Oxford University Press The Royal Marsden Hospital (2003) Spinal Cord Compression Management (online) Available on http://www.ctsevv/qmuc.ac.uk/marsden (accessed 30.7.03) Tywcross R, Wilcock A. (2001) Symptom management in advanced cancer 3rd ed. Radcliffe Medical Press. 3 SECTION 2: INITIAL TREATMENT AND MANAGEMENT 2.1 Patients may present in a variety of health care settings to any health care professional. For the purpose of the pathway it is assumed that the patient presents in primary care. Majority of patients will have a pre-existing known malignancy however some may not have a definite diagnosis. All patients irrespective of known malignancy require urgent admission and assessment. 2.2 Where a patient has no history of primary malignancy they should be referred to the nearest spinal surgery or neurology service. There is a spinal injury team on-call at James Cook University Hospital which can be contacted through South Tees Switchboard. 2.3 Commence on Dexamethasone 16mg immediately (slow iv if possible, subcutaneous or oral whichever can be organised quicker). Intravenous Dexamethasone must be given slowly to avoid sensations of perineal burning (Haas 2003). 2.4 Admit the patient to local Medical Assessment Unit (MAU). For patients in the Hambleton & Richmondshire PCT who would usually be admitted to the Friarage Hospital admit directly to MAU, oncology or the neurology unit at James Cook University Hospital. This is because the Friarage Hospital does not have an MRI Scanner and therefore admission to the Friarage may delay diagnosis to treatment time. 2.5 Role of Dexamethasone High dose steroids should be offered to all patients where feasible. Steroids reduce peri tumour oedema resulting in a reduction of pain, preservation of neurological function and ultimately improve functional outcome after definitive treatment. High doses of steroids may increase the incidence of gastric irritation and fluid retention. The concurrent use of a proton pump inhibitor may be indicated especially if taking a nonsteroidal anti-inflammatory drug. References/Bibliography Doyle D., Hanks W.C. & MacDonald N (1998) Oxford Textbook of Palliative Medicine 2nd ed. Oxford University Press. Haas F. (2003) Management of Malignant Spinal Cord Compression Nursing Times Vol. 99 No. 15 pp 32-34. Posner, J. (1995) Neurologic complications of cancer FA Davis. Philadelphia. 4 SECTION 3: TREATMENT AND MANAGEMENT IN INPATIENT UNIT 3.1 3.2 Responsibilities of Doctor on Admission Patients should be seen urgently on admission. Delays on admission may result in permanent deterioration of neurological functioning. The neurological status should be recorded. Dexamethasone should be administered if this has not already been undertaken by the referring GP (See Section 2). Inform senior medical staff of the patients admission and suspected diagnosis. Organise urgent MRI scan. Some MRI units will only accept referrals from registrars and above. Please refer to local trust policies. (See Section 3). Do not waste unnecessary time by organising bone scans or x-rays. Identify who the results of the MRI scan should be reported to and give necessary contact details to MRI department. Complete request form as specified in Section 4. Assess pain control and prescribe appropriate analgesia. Specialist Palliative Care Teams are available to provide advice if required. If the patient is unable to lie flat for 30 minutes because of pain, adequate sedation/ analgesia must be arranged prior to transfer to MRI department. Inadequate pain control may result in the MRI scan not being carried out, unnecessary wasted time for the radiology department and a delay in the treatment for the patient. Responsibilities of doctor following results of MRI Scan Scan demonstrating spinal cord compression Organise for transfer to the Oncology Department at James Cook University Hospital following discussion with oncologist. Transfer should not be delayed and should be on the same day. Negative scan for spinal cord compression Further investigations may be required which should be organised in collaboration with the consultant responsible for the patients care. Pain and symptom control management should be instigated if not already done so. Referral to the Specialist Palliative Care Team can be made if required. Reduce and/or discontinue Dexamethasone. 5 Patients who were initially referred to MAU, oncology or neurology at James Cook University Hospital from the Hambleton & Richmondshire PCT area should be referred back to the MAU at the Friarage Hospital if considered appropriate and necessary. References/Bibliography The Royal Marsden Hospital (2003) Spinal Cord Compression Management (online) Available on http://www.ctsevv/qmuc.ac.uk/marsden (accessed 30.7.03) 6 SECTION 4: INVESTIGATION PATHWAY MRI scanning is the gold standard investigation of choice. If bone scans and x-rays have previously been undertaken they are useful in evaluating current problems however if they have not been undertaken time should not be wasted in undertaking these investigations. The MRI investigation should be requested urgently. 4.1 Contents of a request form 4.2 Patient details Patient location Relevant clinical findings History and nature of primary malignancy if known History of previous radiotherapy and levels History of previous surgery with details Previous radiological investigations and results Contact details of the referring practitioner i.e. bleep number or other contact details. Referral Process The doctor responsible for the patients care according to Trust policy, should contact the radiologist or the MRI scan room to discuss priority and timing of the examination. The request form will then be immediately delivered or faxed to the MRI Department. If the radiologist has not been immediately available then the referring doctor should leave details of who to contact if further information or discussion is required. NB this information should also be included on the request form. Some patients are unable to be safely imaged with MRI. These cases need to be identified as part of the MRI referral process and alternative imaging should be discussed with the radiologist. 4.3 MRI Examination Patients with saddle anaesthesia, motor weakness or bladder and bowel dysfunction will be scanned the same day, or immediately the following morning if after radiology on call hours. Patients without motor loss, no bladder or bowel dysfunction and only vague sensory disturbance will normally be scanned within 48-72 hours unless there is progressive neurological deterioration. A standard MRI protocol of spinal cord compression will typically involve: Sagittal T1 and T2 (or STIR/FST2) images of the entire spine (cervical spine to sacrum). Axial images through any relevant areas of cord compression. If there is no evidence of neural compression: consider the indications for evaluation of the brain or post contrast T1 images of the spine to exclude intradural metastases. 7 4.4 NB If the patient is unable to lie flat for 30 minutes because of pain adequate provision for analgesia and sedation must be arranged prior to transfer to MRI Department. This will be the responsibility of the referring doctor who should liaise with anaesthetist and the MRI department as appropriate. It may be necessary to give an anxiolytic such as diazepam/lorazepam. 4.5 Reporting of MRI Scan This will be reported at the earliest opportunity by the supervising radiologist. An immediate report will be issued by either: A handwritten report within the patients case notes OR Verbal communication with the referring clinician. A subsequent formal report will be issued and filed with the patients file packet. When necessary a second copy of the films will be sent with the patient to the inpatient unit. 8 SECTION 5: TREATMENT PATHWAY FOLLOWING DIAGNOSIS OF SPINAL CORD COMPRESSION In patients with a known malignancy there are several treatment options: Dexamethasone (See section 2) Decompression surgery Radiotherapy Chemotherapy Patients following transfer from medical assessment units will be admitted into James Cook University Hospital for assessment by an oncologist, if not already an inpatient there. Patients where there is no histological diagnosis should be referred to a neuro or orthopaedic surgeon for assessment. Factors Influencing Choice of Treatment 5.1 Overall picture of the patients’ problem, health status. Acute deterioration of neurological functioning. The site and histology of the primary tumour. Fitness/performance status. NB Poor respiratory function may not be an indicator for not treating as this may be overcome with further treatment. Previous treatment: Has the radiotherapy tolerance dose to the spine already been reached. Previous treatment with radiotherapy which does not ease pain. Tokuhashi score of 5 or below will influence the choice of treatment (Tokuhaski et al 1990, Enkaoua et al 1997, Tomita et al 2001). (See Appendix A) Decompression Surgery and Stabilisation of the Spine Surgery may be indicated in the following situations: Where the primary tumour is unknown. Where there is relapse after radiation treatment. In situations where there is spinal instability or vertebral displacement. Where neurological symptoms progress during radiotherapy. In paralysis of rapid onset. Where tumours are not radiosensitive. Factors limiting surgery include: 5.2 Very poor prognosis (less than 3 months survival) or performance status. Paraplegia should not exclude referral especially if pain is an issue as quality of life may be improved following surgery. Obtaining on Orthopaedic Opinion Oncologists are able to obtain advice from the surgeons on spinal injuries rota at James Cook University Hospital through the switchboard at South Tees Hospitals NHS Trust. 24 hours advice is available through on-call surgeons. 9 Oncologists have the opportunity to discuss patients at the spinal injuries x-ray meetings if timely enough. Meetings are held on a Wednesday lunchtime approximately 12.30pm in the James Cook University Hospital. Contact spinal injuries surgeon secretaries for further information. It is advisable that patients referred for surgery have an ultrasound scan of upper abdomen. This is to contribute to Tokuhashi score. 5.3 Radiotherapy Radiotherapy is the main stay of treatment for malignant spinal cord compression. (Ingham et al 1993) Radiotherapy should be started within 24 hours to maximise recovery chances and minimise function deficits. It is usual to give 5 fractions of radiotherapy. The stability is assessed at MRI. Patients with an unstable spine need to be considered for surgery. If the spine is unstable they should be nursed flat. The oncologist will document in the current history sheets whether the spine is stable. 5.4 Chemotherapy For patients with spinal cord compression caused by chemo responsive tumours e.g. small cell lung cancer and lymphomas, treatment with cytotoxic drugs may be considered. (Mallett & Dougherty 2000). References/Bibliography Enkaoua, E.A., Doursounian, L, Chatellier, G. Mabesoone, F., Aimard, T., Saillant, G. (1997) Vertebral Metastases. Spine Vol. 22 No. 19 p 2293-2298. Guerrero, D. (2003) The Management of Primary Spinal Cord Tumours Nursing Times Vol 99, No. 42, p 28-31. Ingham, J., Beveridge, A. and Cooney, N.J. (1993) The Management of Spinal Cord Compression in patients with Advanced Malignancy. Journal of Pain and Symptom Management Vol. 8, No. 1 p 1-7. Klimo, P., Kestle, J.R.W and Schmidt, M.H. (2003) Treatment of Metastatic Epidural Disease: A review of the literature. Neurosurgical focus Vol. 15 No. 5 p 1-9. Mallett, J. & Dougherty, L. eds (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 5th ed. London. Blackwell Science Limited. Tokuhasi, Y., Matsuzaki, H., Toriyma, S., Kawano, H. & Ohsaka S. (1990) Scoring systems for the Preoperative evaluation of metastatic spine tumour prognosis. Spine Vol. 15. No. 11 p 11101113. Tomita, K., Kawahara, N., Kobayash, T., Yoshida, A., Murakami, H. & Akamaru, T. (2001) Surgical Strategy for Spinal Metastases. Spine Vol. 26 No. 3 p 298-306 10 SECTION 6: REHABILITATION PATHWAY Rehabilitation should begin as soon as possible however this will depend on the stability of the spine and the patient’s pain. Referral to physiotherapist and occupational therapist should be made for all patients immediately following admission to hospital. Before teaching the patient active exercises, the physiotherapist will need to check with the consultant responsible for the patients care if the patient has a stable spine. If the patient doesn’t have a stable spine, the physiotherapist will seek advice regards precautions and limitations to maintain patient safety. This should be documented within the patients notes. However, as soon as it is deemed safe, the patient should commence active leg exercises to prevent the development of contractures, pressure sores and deep vein thromboses. Referrals also need to be considered for social worker, dietitian and palliative care team. 6.1 Physiotherapy 6.1.1 Physiotherapy within Medical Assessment Unit A MRI scan will be used to confirm the presence and location of a spinal cord compression, and assess the stability of the vertebral bodies and joints. If a cord compression is confirmed, the oncologist will decide on the most appropriate course of management. If the patient is due to start radiotherapy, he/she will usually have five fractions over five days and will remain on flat bed rest until the course is complete. Exceptions are only made if the patient is unable to tolerate being flat due to pain, respiratory disease, cardiac problems etc. If the patient is to have surgery, either for decompression or stabilising of the spine, the physiotherapist will liaise with the surgeon regarding pre and post operative management. Upon initial assessment, the physiotherapist will perform a subjective assessment regarding the patient’s previous health, mobility, social circumstances, accommodation and medications. Then he/she will assess the following:o o o o o o General condition Isometric muscle strength Sensation Respiratory condition Pain Sphincter control 11 6.1.2 Physiotherapy During Radiotherapy Treatment The patient will be kept on flat bed rest until radiotherapy is complete. He/she will be assessed daily by the physiotherapist. The physiotherapist will teach the patient breathing exercises to maintain respiratory function and help to prevent the development of chest infections. The patient will be seen daily to review the patient’s chest, but the breathing exercises are to be performed hourly in order to be effective. Active toe, foot and ankle exercises will be taught to maintain circulation and tendo-achilles length. Static quadriceps and hamstring exercises will also be taught to maintain muscle integrity. The physiotherapist will grade these exercises depending on an individual patient’s ability. If the patient’s spine is stable, active leg exercises will be taught, again graded to patient ability. For patients with a cervical cord compression, the physiotherapist will liaise with the oncologist/neurosurgeon regarding management and precautions. If the spine is unstable, the orthotist should be contacted for an assessment for a suitable collar. If the patient has pain, the physiotherapist is able to provide advice on the use of heat/cold therapy, Transcutaneous Electrical Nerve Stimulation (TENS) and positioning. 6.1.3 Physiotherapy Following Radiotherapy Treatment The stability of the spine should be documented by the oncologist in the medical notes (see section 5.3). If the physiotherapist has any queries regarding limits or contraindications, he/she will liaise with the oncologist. Otherwise he/she will use the following protocol. On the first day post radiotherapy, a full assessment of the patient’s lower limb muscle strength will be carried out, and then, will be sat up to 45°, and if tolerated for an hour, up to 90° whilst still in bed. On the second day, the physiotherapist will assess the patient’s sitting balance in bed. If he/she has independent sitting balance and more than grade 3+ muscle strength, sit to stand will also be assessed. If able, progression to dynamic standing and mobilising will be made. If the patient doesn’t have static sitting balance. A hoist will need to be used, though sensitivity should be exercised in introducing it to the patient. If the patient has static sitting balance but is unable to stand, banana board transfers will be practised. 12 6.2 By this point, it is usual that the occupational therapist will have become involved and plans for discharge should be underway. The physiotherapist shall liaise with the community team if necessary, to facilitate the patient’s ensuing discharge. Occupational Therapy The occupational therapist will see the patient within two working days admission to the Oncology Ward to undertake an initial assessment. The occupational therapist will work closely with the physiotherapist and develop their plan of care based upon the patients power within lower limbs, mobility, sitting balance and ability to transfer. Discussions regarding the discharge plan should be started on admission to the oncology ward with the patient, carer and multi-disciplinary team (See Section 9). The occupational therapist will organise appropriate equipment necessary for the patient during admission. The occupational therapist will liaise with the District General Hospital/Community Hospital occupational therapist and wheelchair therapist regarding their assessment of discharge/ongoing care needs. A rehabilitation programme should be established with regular assessments and identification of when intervention should be initiated. The patient and the multi-professional team should set short-term attainable goals to achieve the optimum quality of life. References/Bibliography Hillier, R. & Wee, B. (1997) Palliative Management of Spinal Cord Compression. European Journal of Palliative Care 4(6) p 189-192. 13 SECTION 7: NURSING CARE (Adapted from The Royal Marsden Hospital Manual of Clinical Nursing Procedures). 7.1 7.2 7.3 Care on admission Patients should be nursed flat until the stability of the spine is known; usually following the results of the MRI scan. This is to prevent further compression of the spinal cord which may result in deterioration of nerve functioning. The stability of the spine should be documented in the patients current history sheets by a senior medical practitioner indicating specific instructions for nursing/physiotherapy. Explain and discuss all procedures and investigations with the patient and where appropriate the carer. Reinforce that the aims of any intervention will be the relief of pain and restoration of function if possible. Refer to multi-professional team as appropriate. This should include: Physiotherapist Occupational Therapist Social Worker Dietitian Specialist Palliative Care Team Moving and Handling Ensure that assessment for manual handling is carried out. When the patient needs to be moved e.g. to use a bed pan the patient should be moved carefully to avoid twisting or torsion to the spine. A full assessment of the patients ability to mobilise should be conducted by the multi-professional team (See Section 5). Assessment and Care Planning Monitor and document vital signs, maintaining awareness of signs of spinal shock. Report any signs of spinal shock to the medical team immediately. Assess the patients neurological status including limb strength and sensation. Assess alterations in elimination of urine and faeces – urgency, frequency, level of control over function, retention, constipation and incontinence. Early autonomic and nervous system involvement results in constipation and urinary retention. Incontinence occurs with advanced autonomic nervous system involvement and carries a poor prognosis. Urinary catheterisation may be necessary if retention is present. Conduct procedure using an aseptic technique and undertake catheter care according to local guidelines. 14 In the patient who is paralysed bowel care is important. Patients may become severely constipated due to decreased mobility, spinal innervation, opioids and other analgesics and anorexia. The use of laxatives may result in faecal incontinence which can be problematic for carers to manage at home. Whilst in hospital the patient should be established on a regular plan of bowel care as follows: - Allow the patient to become slightly constipated and use rectal preparations e.g. suppositories or gentle enema to evacuate the bowel every 2-3 days depending on the patients food intake and comfort. The use of a faecal softener i.e. Docusate 1-2 capsules at night will prevent the faeces becoming hard and dry therefore minimising discomfort for the patient. The dose should be titrated against patient need. The above regime should be monitored and adjusted depending on patient needs. Stimulant laxatives should be avoided as this may result in uncontrolled and unmanageable bowel function. Undertake pain assessment using pain assessment tools according to local guidelines. If required administer analgesia as prescribed observing effect and any side effects. Consider use of non-pharmacological interventions such as adjusting position, relaxation and massage. Referral to the Specialist Palliative Care Team may be necessary to provide advice on pain control. Assessment of skin condition. Pressure sores may develop if the patient spends time in bed. Alteration in sensation may mean that stimuli of pain and pressure are not perceived by the patient. The use of pressure relieving aids should be assessed on an individual basis and balanced with the risk of spinal cord transection. This should be assessed jointly with nursing and medical teams, physiotherapist and occupational therapist. 7.4 Facilitate discussion on treatment options between the patient, carer and medical team. Acknowledge and assess the effects of diagnosis and disability on sexual functioning facilitating discussion with the patient and partner if appropriate. Discussions regarding the discharge plan should be started on admission to the Oncology Ward or as soon as level of functioning is ascertained with the patient, carer and multi-disciplinary team . Treatments 7.4.1 Decompression Surgery and Stabilisation of the Spine Provide pre and post operative care according to local guidelines. 15 7.4.2 Radiotherapy Prepare the patient to receive daily radiotherapy treatments by providing appropriate information and education. Support verbal information with written/audio-visual information. Monitor patient for side effects: - 7.4.3 Skin – Erythema over treated area (refer to policy for the management of acute radiotherapy induced skin reactions). Oesophagitis – Administer analgesics and antacids as prescribed; provide soft diet. Nausea/vomiting – Administer antiemetics as prescribed. Diarrhoea – Provide a low fibre diet and administer anti-diarrhoeal medication as appropriate. Dysuria – Increase fluid intake and exclude urinary tract infection by taking an MSU. Chemotherapy Chemotherapy is occasionally used for patients who have a chemo responsive tumour e.g. small cell lung cancer and lymphomas. Prepare the patient to receive chemotherapy by assisting their understanding of information regarding the rationale for chemotherapy and possible side effects. References/Bibliography Mallett, J. & Dougherty, L. eds (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 5th ed. London. Blackwell Science Limited. Pension, J. & Fisher, R.A. (eds) (2002) Palliative Care for People with Cancer 3rd ed. London. Arnold. Skin care working party (2001) Policy for the management of acute radiotherapy induced skin reactions Department of Radiotherapy & Oncology, James Cook University Hospital 2.7.01 16 SECTION 8: PATIENT INFORMATION Early diagnosis is essential in order to ensure prompt treatment and preservation of neurological functioning. Patients who are at risk of developing spinal cord compression should be made aware of potential signs and advised to seek immediate medical help. (Haas 2003, Husband 1998, Held & Peahota 1993). This should be undertaken by the health care professional who recognises that cord compression is a potential complication. Patient information should be given verbally to ensure adequate psychological and physical preparation for tests and interventions. Ongoing assessment should be made to assess the patients understanding of any information given by the multi-professional team. For some patients spinal cord compression means a new diagnosis, for others it is a reminder of disease progression. Information should be imparted with sensitivity and honesty. The majority of patients with dense paraplegia rarely recover. (Hillier & Wee 1997) Verbal information can be supported by written information or audio-visual information e.g. Cancer Bacup, local information leaflets on radiotherapy, chemotherapy. Information provided should be appropriate to patients needs and should take into consideration the patients level of understanding i.e. learning disability, language or any visual/hearing disabilities. References/Bibliography Cancer bacup (2004) What is Spinal Cord Compression? http://www.cancerbacup.org.uk/Qas/393 (accessed 2.1.04) (online) Available at Haas F. (2003) Management of Malignant Spinal Cord Compression Nursing Times Vol 99 No. 15 pp 32 - 34. Held J.L. & Peahota, A. (1993) Nursing Care of the Patient with Spinal Cord Compression Oncology Nursing Forum Vol. 20 No. 10 pp 1507 – 1516. Hillier R. & Wee B. (1997) Palliative Management of Spinal Cord Compression European Journal of Palliative Care Vol. 4 No. 6 p 189 – 192. Husband D.J. (1998) Malignant Spinal Cord Compression : Prospective Study of Delays in Referral and Treatment. British Medical Journal Vol. 317 pp 18 – 21. 17 SECTION 9: CONTINUING CARE FOR PATIENTS WHO ARE PARALYSED Patients will be preferably transferred to either their local district general hospital community hospital if this is not James Cook University Hospital once treatment completed for ongoing care and discharge planning. The co-ordination necessary facilitate discharge home is complex as it requires liaison with a variety of agencies ensure realistic care packages. Communication between the oncology ward and the district general hospital should ensure smooth transfer and continuity of care for patients. Copies of the patients care plans should be forwarded with the patient, along with details of rehabilitation progress made and the patients/carers wishes for ongoing care. Discharge planning should include: - or is to to Assessment of the patients care needs. Assessment of the carers needs. Assessment of equipment and possible adaption needs. Discharge planning should be timely and smoothly co-ordinated. It is likely to involve all the members of the multi-disciplinary team. Community services e.g. GP, Community nurses, Social worker, should be alerted as soon as possible of the patients/carers wishes to be discharged home. The carer should where appropriate be encouraged to participate in the patients care prior to discharge home. This may include the care of catheters, management of medication, transfer skills and the use of any equipment which will be necessary in the home. This is essential to encourage independence and avoid the occurrence of a future crisis. 18 SECTION 10: CONTRIBUTORS NAME TITLE Sarah Jane Ashcroft Dr. Trevor Birnie Helen Boal Liz Boal Maureen Booth David Burliston Occupational Therapist Consultant Palliative Care Project Manager (Cancer Services) Programme Manager Dr. R. Campbell Helen Caudren Dr. Liz Dillon Kate Gowans Dr. Hardman Tracey Haywood Tracy Nevin Mr. Papastefanou Dr. Edwin Pugh Dr. Neil Reynolds Dr. D. Spence Dr. Trewhella Dr. Nick Wadd Jane Walker Christine Ward ADDRESS Senior physiotherapist in Oncology & Haematology Consultant Radiologist Oncology OT Consultant Radiologist Senior Radiographer Consultant Oncologist Physiotherapist Sister, Ward 33 Orthopaedic Surgeon Consultant in Palliative Care General Practitioner Consultant Physician Consultant Radiologist Consultant Oncologist Clinical Manager for Oncology Nurses Consultant in Adult Palliative Care 19 James Cook University Hospital St. Teresa’s Hospice Middlesbrough General Hospital Middlesbrough General Hospital Teesside Hospice James Cook University Hospital James Cook University Hospital James Cook University Hospital Darlington Memorial Hospital James Cook University Hospital James Cook University Hospital James Cook University Hospital University Hospital of North Tees Middlesbrough General Hospital Butterwick Hospice Friarage Hospital University Hospital of North Tees James cook University Hospital James Cook University Hospital Hambleton and Richmondshire Primary Care Trust Appendix A TOKUHASHI EVALUATION SYSTEM FOR THE PROGNOSIS OF METASTATIC SPINE TUMOURS Score 1. 2. 3. 4. 5. 6. Good condition (performance status) Poor (PS 10-40%) Moderate (PS 50-70%) Good (PS 80-100%) 0 1 2 Number of extraspinal bone metastases foci >3 1-2 0 0 1 2 Number of metastases in the vertebral body >3 2 1 0 1 2 Metastases to the major internal organs Unremovable Removable No metastases 0 1 2 Primary site of the cancer Lung, stomach Kidney, liver, uterus Others, unidentified Thyroid, prostate, breast Rectum 0 1 2 Spinal cord palsy Complete Incomplete None 0 1 2 Total = 12 20