Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust

1. Acute Oncology and Palliative Care:
Two Sides of the Same Coin?
Catherine O’Doherty
Consultant in Palliative Medicine, Trust Acute
Oncology Lead, Lead Cancer Clinician
Karen Andrews
Head of Nursing for Macmillan/
Acute Oncology and End of Life
Services

3. Basildon and Thurrock University Hospitals NHS FT
• 650 bed district teaching hospital
• Busy ED: >28000 emergency admissions each year
• Tertiary cardiothoracic centre
• Haematology service: including day case chemotherapy and
intrathecal service
• Oncology out-patient clinics (oncologists based at local
cancer centre)
• 27 bed cancer medicine/ haematology/ palliative care ward

4. Why embed Acute Oncology within palliative care?
• Clinical team experienced in cancer, symptoms and treatment
• Integrated ward
• Team well established within the hospital, working within
hospital systems and processes, known to all staff groups and
accessible
• Potential for more service expansion in both AO and SPC with
additional funding and creative approach to service provision

5. What issues could arise?
• Not all SPC CNSs have radiotherapy/ chemotherapy
experience
• Additional service commitment for a small team
• Potential to detract from focus on specialist palliative care and
non-malignant life-limiting illness

6. Our integrated SPC/ AO service
• September 2011: pilot AO assessment service offering 5 days
a week CNS service
• January 2012: full AO assessment service offering 5 days a
week CNS service with one session from a consultant
oncologist each weekday
• September 2012: full AO assessment service offering 7 days
a week CNS service with one session from a consultant
oncologist each weekday

7. SPC/ AO team
• All CNSs have developed competences in SPC and AO
• Five CNSs and one team leader take part in 7 day rota with
one nurse covering AO each day
• AO CNS will identify all potential AO admissions each day,
triage and see appropriate patients with AO oncologist
• Oncologist based at local cancer centre does one session
each weekday with on call service out of hours
• Haematologist available on site each day with on call service
out of hours
• Palliative medicine consultant input available on site each
weekday with on call service out of hours

8. The AO/ SPC overlap
• Patients who are admitted with complications of cancer,
including a need for end of life care
• Patients who need symptom control because of complications
of treatment
• Patients and families who need psychological, social or
spiritual support
• >90% of our of AO admissions have incurable disease
• >35% of our AO admissions have an SPC need at time of
admission

9. The type 1 patient: a new diagnosis of cancer
• 47 year old lady
• No previous co-morbidities, no significant family history
• Recently made redundant
• Lives with partner and 13 year old son
• Attended A&E with worsening of lower back and hip pain and
admitted under the orthopaedic team
• Gave further history of 8 months of lower back and hip pain
• No loss of weight
• No night sweats or fever
• Had not noticed any lumps
• Tramadol and diazepam unhelpful

10. • MRI lumbar spine and pelvis: bilateral hip effusions,
widespread abnormal marrow signal, no cord
compression but suspicious of metastases from an
unknown primary
• Efforts made to find possible primary revealed right
breast mass with no overlying skin changes and no
lymphadenopathy
• Discussed with AO team who advised:
– CT CAP and bone scan
– Tumour markers
– Refer to breast team for assessment +/- biopsy breast lump

11. • CT CAP: Widely disseminated bony metastases and an
apparent 2.7 cm spiculated soft tissue lesion within the right
breast.
• Bone scan: Multiple foci of increased uptake are seen
scattered in the skull, spine, ribs bilaterally and left scapula
supportive of bone metastases

14. • Breast surgical review: for mammogram, uss and biopsy
• Symptomatically back and hip pain ongoing
– Given Paracetamol 1g QDS
– Ibuprofen 400mg TDS
– MST 20mg BD
• Pain team referral made
• Gabapentin 300mg BD added to analgesia

15. • Patient woke up with new left sided neck pain with decreased
range of movement
– Put down to “sleeping awkwardly”
• Pain team reviewed and noted new neck pain
– Described as a 10/10 shooting pain starting in left ear, radiating
down left neck, left shoulder and left arm
– Associated with left hand numbness
• Changed MST to oxycontin 10mg BD
• Gabapentin changed to pregabalin 50mg BD
• Soft collar fitted

16. • Patient now described the pain as severe
• Developed numbness on the left side of neck
• Severe c-spine tenderness noted
• Oxycontin increased to 20mg BD
• Diazepam was changed to lorazepam
• Urgent MRI arranged but patient was in too much pain to
tolerate it and returned to ward
• MRI called the ward the following day however pain was still
not controlled and therefore scan was cancelled

17. • Reviewed by the anaesthetic team
• Oxycodone stopped.
• Pregabalin increased to 100mg BD
• Fentanyl PCA started
• Pain improved but was still limiting movement
• Reported feeling very constipated and “spaced out”
• A plan was made to try and bring the PCA down

18. • Seen by breast cancer oncologist
• Told that she has metastatic breast cancer
• Incurable but prognosis 5-10 years (median)
• Started on tamoxifen and Zometa with plan to reassess in 2
weeks with Her 2 status
• Referred to SPC team

19. • Reviewed by SPC/ AO CNS (Saturday):
– Worried about possibility of MSCC
– Dexamethasone 16mg OD initiated with PPI cover
– MRI of C-spine advised with analgesia and anxiety management
pre-scan
– Asked for patient to be moved to cancer/ palliative care bed
– Arranged counselling
– Discussed with palliative care consultant and changed fentanyl
PCA to oxycodone 40mg in syringe driver with PRN oral/sc
oxycodone

20. • Seen on SPC ward round
• Oxycodone was helpful but using prn doses– dose increase to 60mg
over 24 hours
• Emotional support given by SPC nurses
• Bone scan reviewed and reattempt at MRI requested urgently
• MRI whole spine successfully performed: C2 vertebral body
appeared completely involved with subtle retropulsion
abutting/indenting the cord and some element of cord compression.

22. • Discussed with MSCC co-ordinator (on call oncologist) who
advised:
– Transfer for radiotherapy first thing in the morning
– Get neurosurgical advice regarding need for a neck collar
• Aspen collar fitted while waiting for Miami-J

23. • Went on to receive 5 fractions of radiotherapy between 21st and 27th
September
• Syringe driver was taken down and converted to oral oxycodone MR
tablets
• Neurosurgical team advised collar would need to be used when
mobilising indefinitely
• Dexamethasone was weaned down
• Pain remained well controlled and patient was discharged after
OT/PT input with monthly follow up in the hospice for zolendronic
acid infusions

24. The type 2 patient: complications of treatment
• 65 year old lady – diagnosed with non-small cell lung cancer
T4 N0 Mx
• Admitted through ED with nausea and vomiting since
chemotherapy (#2 paclitaxel/ carboplatin) 4 days earlier
• Given stat iv ondansetron and metoclopramide, stat iv
ciprofloxacin and iv fluids
• Na 130, K 2.8, U 6.2, Cr 89. Neut 11.4
• Seen by AO team
• Continued iv fluids with electrolyte replacement
• Started on regular iv ondansetron and iv metoclopramide
• Transferred to bed on cancer/ palliative care ward

25. • Day 1: Seen on SPC ward round. Vomiting settled but still
nauseated ++. Unable to eat, drink. Metoclopramide changed
to cyclizine 150mg/24 hours via CSCI
• Day 2: still nauseated - ?problems with CSCI infusion
overnight. Still unable to tolerate anything orally. Cyclizine
continued, levomepromazine used prn
• Day 3: less nauseated. Managed some diet. Used 2 doses
levomepromazine – helpful. Cyclizine changed to
levomepromazine 12.5mg/24 hours

26. • Day 5: Less nausea. Some ‘heartburn’ when eating. Saw dietician.
Continued levomepromazine via CSCI, PPI started
• Day 6: Much better but used 2 prn doses levomepromazine.
Tolerating dietary supplements. Dose in CSCI increased to
18.75mg/24 hours
• Day 7: Eating. Oral thrush noted. Levomepromazine switched to oral
dose, 25mg nocte. Fluconazole started.
• Day 8: Nausea and vomiting resolved. Low K and Mg noted and
replaced.
• Day 9: Discharged home on oral levomepromazine

27. The type 3 patient: complications of known disease
• 44 year old man
• Diagnosed with adenocarcinoma of the lung (T3 N3 M1b) with
metastases to bone
• Seen by oncologist and planned to commence chemotherapy
with pemetrexed and cisplatin
• Prior to planned chemotherapy date, admitted with cough,
green sputum and SOB– treated with iv antibiotics

28. • Received #1 chemotherapy
• 3 days later admitted with cough and increasing SOB. Reviewed by
AO. Received further antibiotics, pleural effusion tapped and oral
candida treated. Discharged home
• Further 12 days later (prior to #2) readmitted with worsening SOB on
to cancer/ palliative care ward under SPC team
• CT CAP: showed progressive lung disease with right lung collapse
secondary to tumour occluding left main bronchus
• Seen by AO team and discussed with usual oncologist

29. • Symptoms managed with steroids, morphine and lorazepam
• Palliative RT arranged – received 5#
• Symptoms improved and discharged home day following completion
of RT with home oxygen and nebuliser
• Readmitted 12 days later (Sunday) with worsening SOB, chest pain
and respiratory secretions
• Seen by AO/SPC CNS in ED
• Wanted to go home if no indication for hospital admission:
equipment and community support already in place

30. • CTPA showed increase in size of lung mass, no PE, no consolidation.
Bloods - no change in WCC and CRP
• Admitted overnight
• Seen on SPC ward round
• Still keen to be at home: decision supported by wife
• Morphine dose increased and steroids increased. IV antibiotic changed
to oral
• Discharged home that day with anticipatory medication and community
support
• Died at home 6 days later

31. In conclusion..
• An integrated AO/ SPC service can work well, especially
where there are no oncology services on site
• The two services enhance one another in:
– Providing rapid access to specialist advice for cancer patients
– Facilitating a cohesive and timely care pathway
– Allowing opportunities to extend services to 7 days

32. From AO to SPC…..bridging the service