14.1 (12.1) Role of the oncologist Flashcards
List five roles of the oncologist in clinical practice
Box 12.1.1
Preventative oncology
◆ Counselling: diet, cigarette smoking, alcohol, environmental
◆ Screening
Diagnostic evaluation
◆ Primary evaluation of the patient with suggestive clinical
findings
◆ Cancer staging
◆ Physiological staging
◆ Goals of care appropriate to tumour type and stage and patient physiological staging.
Communication
◆ Disclosure full and partial
◆ Treatment counselling
◆ Prognostic counselling
◆ Eliciting advanced directives
◆ Patient and family support
◆ Psychological support
◆ Advanced directives
Anti-tumour therapies
◆ Indications
◆ Selection of optimal therapeutic modality
◆ Safe administration
◆ Prevention and management of adverse effects
Symptom control
◆ Physical symptoms
◆ Psychological symptoms
◆ Complications of cancer
◆ Complications of treatment.
Social
◆ Optimization of social supports.
Care of the dying patient
◆ Physical symptoms
◆ Psychological symptoms
WP: Please Don’t COMMUNICATE ANTI-Satan SOCIAL Club. I did it.
List four types of common ethical issues in the care of patients with advanced cancer
Ethical issues related to:
◆ Disclosure of diagnosis and prognosis*
◆ Decision-making (paternalism, autonomy)
◆ Consent: informed, uninformed
◆ Conflicts of interest
◆ When patients refuse or demand treatment*
◆ The right to adequate relief of physical and psychological symptoms and its implications*
◆ End of life:*
* sedation for refractory symptoms
* hydration and nutrition at the end of life
* DNR orders
* use of invasive palliative approaches (nephrostomy or dialysis)
* MAID
What are four principles that are important when discussing prognosis?
A patient asks to know their prognosis what is the first thing you ask the patient?
- Be honest. If you don’t know prognosis, say so.
- Use averages. Not median.
- Emphasize the limits of predictions.
- Caution patients and their families that unexpected events can happen. Suggest that it is worth while to get their affairs in order so they won’t be totally unprepared if something unexpected does happen.
- Avoid nihilism. Never tell a patient ‘There’s nothing more that can be done’ or ‘ Do you want everything done?’ There is ALWAYS something to be done.
- Initiate end of life planning. Sensitively bring up the important subject of advance care planning
- Commit to non-abandonment. Reassure the patient you will continue to care for him or her, whatever happens.
First question: what is patient’s motive in asking this question (to plan versus seek reassurance that things are not so serious)
List 4 techniques for augmenting hope when discussion that curative treatment is not possible
(1) explore realistic goals
(2) emphasize what can be done (particularly control of physical symptoms, emotional support, care and dignity, and
practical support)
(3) discuss issues related to day-to-day living*** (mindfulness)
(4) focusing of meaning in significant relationships***
Transform hope
List 4 recommendations in regards to communication that enhances hope?
- Be honest and open in prognostic discussion
- Offer reassurance that patient/caregiver will be supported throughout
- Emphasize what can be done
- Reassure many treatments for symptoms
- Identify areas where control can be fostered (e.g. advanced care planning)
- Recognize many forms of hope that are possible even in the face of terminal illness
List three models for the delivery of oncology care and palliative care to patients. What is the main advantage of each
Sequential care model - In this model the patients is cared for by the oncology service as long as there is potential benefit in disease-modifying treatment.
Benefits: clear delineation of responsibility, enables the oncologist to focus on onc
Oncologist based palliative care - In this model, the oncologist assumes the role of coordinating care and providing both anti-cancer and palliative care services (consulting pall MD on PRN basis)
Benefits: The major advantage of this approach is its emphasis on continuity of care
Concurrent model - In this model, patients with advanced cancer are jointly cared for by both oncology and palliative medicine specialists
Benefit: continuity of care, data show improved patient outcomes
What the six minimum requirements for palliative care delivery at an oncology centre?
Box 14.1.5
- Centre provides closely integrated oncology and pall clinical services
- Centre is committed to continuity of care
- Centre providers high level home care with expert back up and coordination of home care
- Centre incorporates support of family
- Centre provides routine patient assessment of physical/psychological symptoms and social supports
- Centre incorporates expert medical and nursing care in evaluation and relief of symptoms
- Centre incorporates expert medical and nursing care in evaluation and relief of existential distress
- Centre provides emergency care of inadequately relieved symptoms
- Centre provides facilities and expert care for inpatient symptom stabilization
- Centre provides respite care
- Centre provides facilities and care for EOL patients
- Centre participates in research related to QOL of cancer patients
- Centre in involved in clinical education to integration of oncology and palliative care
Care at community (home)
Care in ER setting
Care in cancer centre
Care in PCU
Care for EOL
Interdisciplinary care
Symptom + supports
Academic work: education and research
List four reasons re: delay in referral for pall care consults
persistent beliefs that palliative care has an alternative philosophy of care incompatible with cancer therapy*
lack of knowledge about locally available services*
oncologist and patient reluctance to address issues implying incurability
optimism that third- or fourth-line salvage treatments will prolong survival or improve quality of life
fears that a palliative care referral will undermine hope or shortens the patient’s life
Oncologists sometimes express reluctance about palliative care referrals for fear that anti-tumour treatment strategies will be challenged or that the patient will be ‘stolen’*
Lack of recognition by oncologist that patient is deteriorating*
FS:
- pall = EOL
- pall will stop anti tumor tx
- lack of knowledge of services
- lack of knowledge of deterioration
