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Recognising illness in Recognising illness in the Terminal Stage the Terminal Stage Mr Aali Sheen Mr Aali Sheen 10 10 th th October 2015 October 2015

Recognising illness in the Terminal Stage Mr Aali Sheen 10 th October 2015

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Recognising illness in the Recognising illness in the Terminal StageTerminal Stage

Mr Aali SheenMr Aali Sheen

1010thth October 2015 October 2015

Who am I?Who am I?

Consultant General SurgeonConsultant General Surgeon

Hepatopancreatobiliary specialistHepatopancreatobiliary specialist

Abdominal wall and HerniaAbdominal wall and Hernia

Medical school 1993Medical school 1993

Trained in London, Leeds and ManchesterTrained in London, Leeds and Manchester

Appointed Consultant in 2005Appointed Consultant in 2005

Undertaken 450 Liver/GB; 101 Pancreas Undertaken 450 Liver/GB; 101 Pancreas resections for cancerresections for cancer

IntroductionIntroduction

Diagnosis of cancer is not always easyDiagnosis of cancer is not always easy

Cardinal signsCardinal signs

Soft signsSoft signs

Can always be missedCan always be missed

Cased based scenariosCased based scenarios– StraightforwardStraightforward– More difficult in interpretationMore difficult in interpretation

Early symptomsEarly symptoms

Generally feeling unwellGenerally feeling unwell

‘‘Not Right”Not Right”

HavenHaven’’t been the samet been the same

Going on for a few monthsGoing on for a few months

Occasional tummy pain but nothing Occasional tummy pain but nothing seriousserious

But I was eating fine up until last weekBut I was eating fine up until last week

Cardinal symptomsCardinal symptoms

Weight lossWeight loss

Abdominal discomfortAbdominal discomfort

Poor appetitePoor appetite

Altered bowel habitAltered bowel habit

PR bleedingPR bleeding

DysphagiaDysphagia

OdynophagiaOdynophagia

HaemoptysisHaemoptysis

SignsSigns

Increasing ageIncreasing age

Recent change in lifestyleRecent change in lifestyle

Thin (not always)Thin (not always)

CachecticCachectic

JaundicedJaundiced

Abdominal distensionAbdominal distension

Lump – SJ noduleLump – SJ nodule

How can we tell?How can we tell?

Case 1Case 1

69 year old man69 year old man

Likes his drinkLikes his drink

Noted tummy swellingNoted tummy swelling

Feels otherwise okFeels otherwise ok

Eating plentyEating plenty

Thought he should come and see you?Thought he should come and see you?

Tests??Tests??

Ultrasound?Ultrasound?

Routine serum investigationsRoutine serum investigations

Cancer pathwayCancer pathway

Immediate referral to Specialist and Immediate referral to Specialist and Cancer MDTCancer MDT

Tumour markers – can be undertaken in Tumour markers – can be undertaken in hospitalhospital

HepatomaHepatoma

History predicts problemHistory predicts problem

Diagnosis often lateDiagnosis often late

CirrhosisCirrhosis

Options for cure are limitedOptions for cure are limited– Surgery if Childs ASurgery if Childs A– TACETACE– AblationAblation– ChemotherapyChemotherapy

Case 2Case 2

35 year old patient mother of three35 year old patient mother of three

Feels awfulFeels awful

Jaundiced !Jaundiced !

Bilirubin – 275Bilirubin – 275

Admission to Hospital – donAdmission to Hospital – don’’t take no for t take no for an answer – Call the Consultantan answer – Call the Consultant

InvestigationsInvestigations

Relief of Jaundice failed with ERCPRelief of Jaundice failed with ERCP

Tight distal bile duct stricture ? StonesTight distal bile duct stricture ? Stones

Percutaneous drain inserted – could not Percutaneous drain inserted – could not bypass stricture – is this malignant?bypass stricture – is this malignant?

Patient deterioratingPatient deteriorating

Died 30 after admissionDied 30 after admission

DiagnosisDiagnosis

Malignant cholangiocarcinoma – on a Malignant cholangiocarcinoma – on a background of choledochal cystsbackground of choledochal cysts

Poor overall prognosisPoor overall prognosis

Take home messageTake home message

Very high Bilirubin!Very high Bilirubin!

It’s ok for a transient rise but not to a very high It’s ok for a transient rise but not to a very high levellevel

Case 3Case 3

55 year old lady with UC complained of a 55 year old lady with UC complained of a low Hblow Hb

Investigated with colonoscopy – no tumourInvestigated with colonoscopy – no tumour

Gastroscopy normalGastroscopy normal

Bloods show a mild anaemiaBloods show a mild anaemia

No obvious other abnormalitiesNo obvious other abnormalities

What next??What next??

Blood filmBlood film

Bone marrowBone marrow

Abdominal imagingAbdominal imaging

UltrasoundUltrasound– Dilated ducts on the left lobe onlyDilated ducts on the left lobe only– Normal LFTsNormal LFTs

CAT scan ?CAT scan ?

X-sectional imaging showed possible PSCX-sectional imaging showed possible PSC

Segmental cholangiocarcinoma is a worrySegmental cholangiocarcinoma is a worry

Needs surgeryNeeds surgery

Chemotherapy not ideal for this cancerChemotherapy not ideal for this cancer

Surgery undertaken – patient wellSurgery undertaken – patient well

What to look out for?What to look out for?

Unexplained weight lossUnexplained weight loss

Bleeding – Vomit/PR/PVBleeding – Vomit/PR/PV

Persistent heartburn or indigestionPersistent heartburn or indigestion

Altered bowel habitAltered bowel habit

JaundiceJaundice

HaempotysisHaempotysis

Breast LumpBreast Lump

Abnormal persistent lump Abnormal persistent lump

Terminal CancerTerminal Cancer

Review care needs and goals of care with resident (if Review care needs and goals of care with resident (if able), family and GPable), family and GP

Implement palliative care plan or pathwayImplement palliative care plan or pathway

Ensure care given is in line with previous direction Ensure care given is in line with previous direction from the resident, if they are now unable to give from the resident, if they are now unable to give directiondirection

Manage symptoms appropriatelyManage symptoms appropriately

Withdraw treatments, activities, medication that are no Withdraw treatments, activities, medication that are no longer appropriate or benefiting the residentlonger appropriate or benefiting the resident

Provide counselling and support, to the resident, Provide counselling and support, to the resident, family and staff.family and staff.

Three triggers !Three triggers !

The Surprise Question "Would you be The Surprise Question "Would you be surprised if this patient were to die in the surprised if this patient were to die in the next few months, weeks, days'?"next few months, weeks, days'?"

General indicators of decline - General indicators of decline - deterioration, increasing need or choice for deterioration, increasing need or choice for no further active careno further active care

Specific clinical indicators related to Specific clinical indicators related to certain conditions (unresolving jaundice).certain conditions (unresolving jaundice).

GuidanceGuidance

Three case scenariosThree case scenarios

69 year old woman with terminal cancer69 year old woman with terminal cancer

84 year old with deteriorating medical 84 year old with deteriorating medical conditioncondition

91 year old lady with chronic condition91 year old lady with chronic condition

GSF guidanceGSF guidance

A – BlueA – Blue– Diagnosis – Stable with a year + prognosisDiagnosis – Stable with a year + prognosis

B – GreenB – Green– Unstable, Advanced diseaseUnstable, Advanced disease

C – YellowC – Yellow– Deteriorating, weeks prognosisDeteriorating, weeks prognosis

D – RedD – Red– Terminal care, final daysTerminal care, final days

NAVY After careNAVY After care

Change in Patient’s statusChange in Patient’s status

Weight loss (more than 10% of body Weight loss (more than 10% of body weight in last 6 months); BMI below 18weight in last 6 months); BMI below 18

Serum albumin less than 25g/lSerum albumin less than 25g/l

General physical decline; dependent in General physical decline; dependent in ADL’s, bed / chair fastADL’s, bed / chair fast

Multiple diseases impacting on wellbeingMultiple diseases impacting on wellbeing

Increased frequency of admissions to Increased frequency of admissions to acute care.acute care.

End of lifeEnd of life

Prepare family for passing awayPrepare family for passing away

Unexpected when it finally happensUnexpected when it finally happens

Painful for all involvedPainful for all involved

Try not to expect them to know to much Try not to expect them to know to much information – as all the information they information – as all the information they have received may not have ‘got through’have received may not have ‘got through’

Best to let them ask any questions ?Best to let them ask any questions ?

SummarySummary

High index of suspicionHigh index of suspicion

Severe abnormality in blood tests should Severe abnormality in blood tests should raise alarm bellsraise alarm bells

Increasing age is important but younger Increasing age is important but younger patients usually present late with advanced patients usually present late with advanced disease - If in doubt please refer ondisease - If in doubt please refer on

Triggers Triggers

Preparation for death is never easyPreparation for death is never easy

Useful LinksUseful Links

NICENICE– http://www.nice.org.uk/guidance/cg27/chapter/http://www.nice.org.uk/guidance/cg27/chapter/

guidanceguidance

MacmillanMacmillan– http://www.macmillan.org.uk/information-and-http://www.macmillan.org.uk/information-and-

support/diagnosing/how-cancers-are-diagnosed/support/diagnosing/how-cancers-are-diagnosed/signs-and-symptoms/signs-and-symptoms.htmlsigns-and-symptoms/signs-and-symptoms.html

Cancer research UKCancer research UK– http://www.cancerresearchuk.org/about-cancer/http://www.cancerresearchuk.org/about-cancer/

cancer-symptomscancer-symptoms

Thanks to HCAThanks to HCA

Clare EvansClare Evans

www.manchestergeneralsurgery.co.uk

www.manchesterherniaclinic.com