COVER SHEET

Reflections on the care of a Patient with Palliative Care Needs

Final Register Number: 25321902
Date: 25/12/2019
I declare that this is wholly my work, except where acknowledged
specifically, as the published work of others.
Total Word Count: 1583
Word count of Learning Part (step III): 1050
I.INTRODUCTION

I am working as an assistant professor in a cancer hospital and

research centre in surgical department, which i have joined recently. I
have in the field of cancer treatment from the last 5years. My line of
work includes evaluating patient as an out-patient, giving counselling
about the disease, pre-operative workup, surgery and post-operative
care and follow up of patients during visits.

II.CASE SUMMARY

DIAGNOSIS: -
Mr.” X’’ is a 30 year old married women diagnosed as well
differentiated squamous cell carcinoma of suraglottis locally
advanced (cT4 N3 M0) in nature on August 2019 at our hospital and
during the evaluation. She was planned for Neoadjuvant
chemotherapy followed by definitive radiation. She was unable to
swallow food so she was referred to us for providing enteral feeding
by doing a Feeding jejunostomy (palliative) before starting the
therapy as dysphagia is severe.
The procedure is explained to her and she underwent the above said
procedure in September 2019 under high risk because she was not an
ideal candidate for endotracheal intubation because of the tracheal
compression of the mass. She was explained about the option of
palliative elective tracheostomy because of the compression but she
was not willing to undergo the same as she has no dyspnoea. She was
discharged and review date was advised.
1 cycle of chemotherapy was given with Carboplatin and Paclitaxel .
Suture removal was done on post operative day(POD) 11. By POD 12
she developed burst abdomen with complete rectus dehiscence. She
underwent emergency secondary suturing on the same day.
During the post operative period of the second surgery, her saturations
were not maintaining on room air and even on oxygen. She was
counselled about the need for tracheostmy and underwent the same as
an emergency procedure on POD 2.

INVESTIGATIONS
INVESTIGATIONS DONE REASON WHY THE
INVESTIGATIONS WAS DONE

Hopkins examination To know local extent of disease

CECT head, neack and thorax Local extent and any metastatic
spread of disease
FNAC of cervical nodes Histological confirmation of disease
CBC, coagulation profile Counts for chemotherapy, surgical
workup

OUT COME OF PATIENT MANAGEMENT:

In the care of patient, I had taken the help of Head and Neck
surgeons, medical oncologists, anesthesiologist their contributions
helped the patient greatly by diagnosing the disease condition and for
complete surgical care needed during the surgery. With the help of
palliative care medicine pain due to the local extension of the disease
was also addressed.
III LEARNING OF PALLIATIVE CARE PRINCIPLES AND
PRACTICE

As a surgical oncologist in palliative care I am trying to incorporate

palliative care knowledge in my daily practices. Attending this course
I came to realize that introduction of palliative care services at the
time of diagnosis of cancers leads to meaningful improvement in the
experiences of patient and family care givers by emphasizing
symptoms management, quality of life and treatment planning
especially for cases which are locally advanced or metastatic which
are not operable and also to those patients who are not physically fit
to undergo surgery.
Palliative care enhanced my knowledge regarding assessing pain by
using different pain scales on both adults and in paediatrics ,different
pain relieving drugs like opioids weak and strong opioids like
morphine which helps most of the cancer patients by tremendously
controlling their pain which will improve the quality of the life even
with the disease burden they are carrying.
I should be much sensitive regarding issues during revealing the
diagnosis of cancer to the patient, feel empathy, understanding patient
& family members concern during this process. I learned to go for an
open ended question during this process and the method of relieving
the fears in patients. Giving time for each patient during revealing the
diagnosis and stage of disease is of much importance.
My comprehensive care not only involves the diagnosis and pain
relief but also should concern patients physical, psychological, social,
spiritual and financial fears of the patient.
Now I am trying to habituate in spending time with patients and
hearing their problems with patience. This helps them in disclosing all
type of issues they are facing. Some patients might not open up in a
single visit and each patient needs a new way to be approached with
to be taken care of.

PHYSICAL CARE: -
Pain- Goal is control pain by assessing pain by the help of the WHO
step ladder for pain control. Palliative care physician had prescribed
Tab Paracetmol 650mg TID, Tab Morphine 10mg TID and Tab
Dexamethosone 4mg OD

Feeding Jejunostomy - Patient was only on less amount of fluid diet

in order to meet nutritional needs. She was advised for feeding
jejunostomy and explained about importance of enteral feeding
required during the chemotherapy.
The required home care for the jejunostomy was explained by
requirement of regular dressings, to pour only liquids which can
easily pass through the tube, filter any liquids which can have
particles, to pour clear water at the end of each feed to prevent
clogging with any material/discharge from the bowel.
I gave enough information regarding the requirement of elective
tracheostomy required to prevent dyspnoea due to further
compression over trachea for which the patient was not willing before
the first procedure. She developed dyspnoea after the emergency
procedure for which she underwent emergency tracheostomy.

PSYCOLOGICAL CARE: -
She has social stigma because of swelling over neck during the initial
visits to our hospital. She is concerned about the family as her
primary care giver is her brother and has no support from her husband
or her other family members during the primary visits. During her
later visits she is concerned regarding feeding jejunostomy on
abdomen. Psychological pain was evident upon with patient
Her brother was also depressed since the diagnosis and the following
events that were needed for the treatment. After counselling session
by the palliative care physician he was able to accept the condition.
During the admission for the emergency procedure of suturing her
husband came. He feels he cant help his wife.
Brother and husband understood that the surgical procedures were to
relieve symptoms and not curative in intent. The primary treatment is
by chemotherapy and radiation. I have explained to the patient and
family members that the disease is non communicable she can do all
his daily activities as usual. Feeding jejunostomy tube and
tracheostomy tube is not at all barriers for his daily activities. In order
to reduce the social stigma of the patient she was advised to keep one
towel on around on neck to cover the tracheostomy tube and to cover
the jejunostomy tube under saree or to wear a full clad while going
into public.

SPIRITUAL CARE: -
She stopped believing on god and family wondered why this
happened to them. She believes prayers will not give any more
relaxation to his but will be going to church to find peace. She was
counselled to accept the disease prognosis and the given treatments
are to bring down symptoms and not to cure the disease.

ISSUES OF COMMUNICATIN WITH PATIENT AND FAMILY: -

Brother has accepted her disease prognosis and is giving support in
her daily activities. Husband and other family members need more
counselling to know and accept the disease prognosis.

ETHICAL ISSUES: -
I respected his autonomy but at first the patient rejected to do
tracheostomy and feeding jejunostomy. I and palliative care physician
explained about benefits of having feeding jejunostomy and
tracheostomy as it would help in easing the treatment.
She was accepting for feeding jejunostomy but was still
uncomfortable about the tracheostomy. She was counselled about the
tracheostomy requirement again before being discharged.

IV POLICY AND INNOVATIONS IN PRACTICE IN OUR FIELD

WORK BASED ON THIS CASE REFLECTION: -
As an oncologist my professional oath is to provide comprehensive
care to all patients. But delivery of care focused only pre operative
evaluation, intraoperatively and post recovery of patients.
After attending this course I have gained some knowledge and skills
to my routine practice I have extended my delivery of care by
applying all palliative care principles in all physical, psychological,
social and spiritual areas.
I am now assessing pain with pain scales. During counselling sessions
I am using SPIKES. I am also practicing to listen more to understand
what the patient concerns are.
I make follow up calls to know the condition of the patient when
needed. As a palliative care member it is not about cure and it should
be to provide comfort to the patient and deal with symptoms well and
i should still improve myself and improvise with each patient as all
would not respond in the same way.

ADD LIFE TO THE DAYS

NOT DAYS TO THE LIFE
This should be my present goal in palliation

V) REFERENCE AND REFERENCING: -

1. Patient, family members, case sheet and doctor.

2. Journal of the new castle on. Tyne and northern counties medical
society
3. M R Raj Gopal et ai, india; opoid availability .an update, j pain and
symptoms management, nov 2016
4. https;//hospice care .com
5. Chaturvedisk, shenoy.a. a, prasadkm, etal. concerns, coping and
quality of life.
6. Oncology secretes Rose a gates 3 rd edition.
7. Text book for certificate course in essentials of palliative care,5 th
edition ,IAPC.

Thank you