Cover sheet

Reflections on the care of a Patient with Palliative Care Needs

Register Number: 12121602

Date: 1/1/2017

I declare that this is wholly my work, where acknowledged specifically, as the published or

unpublished work of others

Total word count : 1848

Word count of learning Part (Step III): 1188

I Introduction

I am a family physician working in the department of the community health in a private mission

hospital. I have been practicing in this department for the past one year. My association with the

palliative medicine started since then. My interest in this field developed as I saw the work done

in the palliative department in my hospital. I was touched by the impact they made on the lives

of people even in their death both in rural and urban settings.

II. Case summary

1. What was the diagnosis? Enumerate all the important clinical features, including

physical findings.

I have selected a case of ductal carcinoma breast stage III. Patient noticed right side breast lump

and sought attention only after she developed pain a year later. She underwent treatment in a

private hospital involving a partial mastectomy initially. She then had a recurrence hence

underwent modified radical mastectomy. This was followed by radiation therapy and three

cycles of modified neo adjuvant chemotherapy and then second line chemotherapy. As part of

my hospitals palliative teams home visit I had visited this patient and she presented with

complaints of right side pain and tenderness over the 2nd and 3rd ribs along with lymphedema of

right upper limb.

What investigations did u do and why? Complete the following table.

Investigations done Reason

1) Chest radiograph To look for bony lesions
2) Bone scan To assess for bony metastasis
3) Doppler right upper limb To rule out deep venous thrombosis
4) Complete blood counts To assess for anemia
 2. Final outcome of patient management with the following details:

a) What was the result? Was the result expected/anticipated?

b) Who else did you involve or consult in the care of this patient?

c) Were their contributions helpful? If yes, how?

The patient was diagnosed with stage III disease but on this visit, we had features

suggestive of bony involvement probably indicating skeletal metastasis. We discussed this

possibility with the patient and she was very upset to hear it and with the help of our team of

nurses, counsellor and chaplain we were able to provide her with some support.

We wanted to give her diclofenac but as she had already used it and developed allergic reaction

(itching) we provided her with T. Tramdol 50mg twice daily for pain relief. She also had

lymphoedema secondary to the surgery done earlier. We reinforced the need for physiotherapy

for reduction of the swelling and also the swelling had worsened recently hence we wanted a

venous Doppler to be done for the same.

The patient was very distraught and devastated to hear that the disease may have progressed. For

her the possibility of disease progression meant death and she was not ready to face such a

possibility now. we involved our counselor and chaplain to provide her with counseling,

emotional and spiritual support. The patient expressed her concern about her elder son who did

not have a job. We involved our social worker to review the sons prospects for a job and if

possible to see if he would fit into any job profile in our hospital itself.

We advised the patient to review with her oncologist with the investigations we had suggested

and to also discuss further treatment options in this situation.

III. Candidates learning of palliative care principles and practice.

Physical care:

The patient had two issue physically one was that of pain and the other was that of lymphedema.

Pain is a difficult symptom to treat but WHO has laid a clear plan on how it needs to be dealt

with.

In recognizing the need for improved pain management worldwide, the World Health
Organization (WHO)1 instituted a three-step analgesic ladder as a basis for pain management

Step 1 - Mild Pain: acetaminophen or NSAID +/- adjuvant.

Step 2 - Mild to Moderate: weaker opioid for mild to moderate pain + acetaminophen or
NSAID +/- adjuvant.

Step 3 - Moderate to Severe Pain: stronger opioid for moderate to severe pain +
acetaminophen or NSAID +/- adjuvant.

The WHO also recommended that in the relief of cancer pain, medication be given according to
the following framework:

By Mouth
o Oral administration of medication is an effective and inexpensive method of
medicating patients and should be used when possible. Medicines are easy to
titrate using this route and are therefore the preferred method of administration.
Around the Clock
o Patients should receive their pain medicines throughout the day either by routine
administration or by sustained release preparations. This allows for continuous
pain relief and minimizes the episodes of pain the patient may suffer throughout a
24-hour period. The goal is to prevent pain rather than react to pain.
 By the Ladder
o The types of pain medications should be changed according to the severity of the
pain, using the WHO stepwise approach as a guide to maximize pain relief.
On an Individual Basis
o Each patient should be treated individually. Patients may require different dosages
and/or interventions in order to attain good symptom relief.
With Attention to Detail2
o Patients need to be closely monitored for the efficacy of the intervention and the
appearance of side effects during therapy. The WHO has taken the initiative to
advocate aggressive treatment of pain. It has recommended to practitioners that
regimens be individualized for each patient and that pain generally can be well
controlled by the appropriate use of opioids.

The patient had lymphedema secondary to the surgery done earlier. It was stage-I lymphedema.

In this stage the patient was taught arm elevation and exercise using daily activities like drying

clothes on a clothes line. She was educated on the donts so prevent worsening of the

lymphedema like carrying heavy weights.

As I went through the literature I found of the following evidences for lymphedema treatment.

Non-Invasive Components of Care

o Compression bandaging includes several layers of short-stretch bandages that cover
the entire limb and create an effective gradient pressure to move lymph fluid out of
congested areas.
o Exercise is prescribed depending on the severity of Breast Cancer Related
Lymphoedema symptoms. Remedial exercises are prescribed initially when the goal
is to reduce swelling in the extremity. Aerobic, strengthening, and flexibility
exercises are prescribed in the self-management phase.
o Skin care is essential for lymphedema management and includes meticulous hygiene
and ongoing observation for breaks or texture changes in the skin
 Surgical Management
o Nodal Status Determination: Breast cancer surgery has historically included nodal
biopsy and removal in order to detect metastasis and aid in staging. With the advent
of sentinel lymph node biopsy (SLNB), studies have changed surgical protocols in
regard to the necessity of axillary lymph node dissection (ALND) and in decreasing
the number of nodes necessary for ALND
o Advances in surgical procedures are currently under investigation for both prevention
and treatment of lymphedema using excisional operations, lymphatic reconstruction,
and tissue transfer; however, surgery is not considered first-line treatment for
lymphedema.
Adjunct Therapies
o Pneumatic Compression Therapy: Intermittent pneumatic compression (IPC),
consisting of a sleeve garment with chambers that apply pressure, simulating the
work-and-release method of manual compression, is used in reducing edema
o Aqua lymphatic therapy is a method that uses the viscosity of water to provide
resistance to body movement. Hydrostatic pressure is used to protect the arm from
swelling and reduces edema.
o Complementary and alternative medicine (CAM) is used by as many as 75% of
women with breast cancer as a means to cope with side effects from conventional
treatment, find solace, and facilitate healing and cure
o Low-level-laser therapy (LLLT) is another treatment modality that has been studied
as an adjunct or alternative in reducing fluid volume and improving arm function in
women who have BCRL

Regardless of the type of adjunct therapy, it is important patients communicate with health care

providers to prevent possible adverse effects from combining therapies, prevent injury, and

discuss resources that can most benefit patients.

Psychosocial care:

Patient was deserted by her husband as soon she was diagnosed with carcinoma breast

this has led her to develop poor self-image. Because of this situation, she is taken care of

by her aged mother. She has two sons 19yrs and 17yrs old. The eldest is a school dropout

and is wayward. Her main concern was her elder son. This training program made me

realize that it is important to address patient concerns so that wholistic care can be

provided. Hence, we made efforts to help her in this situation.

Spiritual care

The patient was distressed and very much upset with the situation. She was feeling bad her aged

mother had to take care of her, her husband has deserted her, her children are not settled in life

and that she probably very little time left in this world. All these thoughts have made her feel

alone and hopeless with nothing to look forward in life. This is the moment that people look

beyond human for support and my patient was also looking for the divine help. We helped her

reach out to God and encouraged her to believe in God and hold on to her faith and live in Hope.

Issues of communication with patient and family

This training program has helped me to improve my communication skills. I learnt

listening is the most important part of communication and not to react in difficult

situations but to respond in an empathetic manner. I learnt that allowing them to vent out

their feeling is a part of therapy even though we may not be in a position to solve their

problems.
 Ethical issues if present

There were no ethical issues associated with this case.

V) How will you influence policy and innovations in practice in your field of work

based on this case reflection?

Prior to this contact session I used to consider only physical signs and symptoms required

to treat the patient. But with this knowledge of palliative care it is indeed going to help

my practice whereby I have developed better communication skills, whereby I can build a

rapport with the patient, develop the ability to get the patient into confidence, empathize

with the patient, counsel the patient. There are many conditions in dentistry which needs

counseling and total care of the patients and indeed this is going to help me in future and

I hope palliative care becomes a responsibility of each doctor rather than merely

practicing in treating physical symptoms.

VI) References:

1. World Health Organization. Cancer Pain Relief and Palliative Care: Report of a WHO

Expert Committee. Geneva, Switzerland: WHO; 1990. Technical report series, 0512-

3054;804.

2. World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability. 2nd

ed. Geneva, Switzerland: WHO; 1996.

3. Surveillance Recommendations in Reducing Risk of and Optimally Managing Breast

Cancer-Related Lymphedema: J Pers Med. 2014 Sep; 4(3): 424447.