This document discusses caring for people with both cancer and dementia. It notes that the prevalence of both diseases is rising as the population ages. People with both conditions present unique challenges for clinical care. The document also presents a case study of a woman named Mary admitted to the hospital with lymphoma and dementia, and how a person-centered approach to her care improved her quality of life and outcomes. It emphasizes the importance of communication, recognizing each patient's individual needs and personhood, and supporting patients and caregivers.

1. The Christie NHS Foundation Trust
Ethics, Dilemmas and Decisions in
Caring for People with Cancer with
Dementia
Lorraine Burgess
Macmillan Dementia Consultant Nurse
The Christie Hospital NHS Foundation
Trust

2. The Christie NHS Foundation Trust
Dementia Clinical NICE Guidelines 42 ( DOH)
“Dementia Care should incorporate a person centred approach from
the time of diagnosis until death. The aim should be to achieve best
quality of life for the people with Dementia and enable the person with
dementia to die with dignity in a place of their choice and to support
carers during their bereavement in anticipation of or following death”.
DOH ( 2006)

3. The Christie NHS Foundation Trust
Commission on Hospital Care for Frail Older People
• A BASIC CHECKLIST FOR BETTER - CARE PROVISION FOR FRAIL OLDER
PEOPLE
• 1. A workforce skilled in both health and social care that recognises the specific
needs of older people, values them as individuals, involves them in care and relates
to them in a compassionate way. Older people in hospital need to be supported to
manage transitions, improve their health and be guided to a good end of life, where
appropriate, in a place of their choice.
• 2. A health and care system with a serious, sustained emphasis on healthy ageing,
exercise and prevention to address the determinants of need.
• 3. Primary and community clinicians who are equipped to assess and manage older
people with multiple long term conditions properly, in longer consultations which
include meaningful care planning.
• 4. “Rapid response at home” services for frail older people, in which “first responders”
would work with ambulance trusts to see if the older person can be treated safely and
successfully at home (including care homes).
• 5. Care planning decisions that are taken very early, and by senior clinicians,
when older people require hospital treatment. This minimises ward moves and
leads to the right treatment by the right professionals with no delays and timely
discharge.

4. The Christie NHS Foundation Trust
NHS Five Year Vision
Acute hospitals and Integrated Care
•A core part of the vision in the NHS five year forward view is a
fundamentally different role for acute hospitals. Hospitals in England
and elsewhere face significant challenges as a result of rising demand
and the changing needs of the population, and they will not be able to
meet these challenges by continuing to work alone. Instead, acute trust
leaders need to embrace a system-wide perspective and work
increasingly closely with primary care, community services, social care
and others

5. The Christie NHS Foundation Trust
Dementia and Cancer
Setting the scene…………….

6. The Christie NHS Foundation Trust
Dementia and Cancer
• Ageing population has led to rapid increase in prevalence of
dementia. In 2030 70% of all cancers will occur in elderly people
• Both diseases of the older person
• Safe to assume that co-existence is high
• Individuals with both conditions pose unique challenges in clinical
practice owing to impairments in understanding, communication,
capacity to consent and issues related to dying
• Relatives are often called to address and make surrogate decisions
which can be distressing for both person with dementia and relative.

7. The Christie NHS Foundation Trust
Dementia and Cancer
• Lower rates of cancer in people with dementia
• Under diagnosis - under report symptoms- more advanced stages
often to late to be treated - half of population accidently discovered
• Treatment is individual – require discussions that risk may outweigh
the benefits. QoL in longer term should be an outcome.
• Little known about care given to small number of patients who have
both conditions but some studies suggest poor care and suffering.
Soloman et al (2013)

8. The Christie NHS Foundation Trust
The relationship between cancer and dementia
Lack of studies looking at this relationship
Mainly focus on mortality
Patients often complain of cognitive dysfunction
Often related to treatment side affects, fatigue, depression etc
(Rogers et al, 2008)
Some studies show an inverse relationship
Lower rates of Alzheimer’s in cancer survivors
Lower rates of cancer in people with Alzheimer’s
(Roe et al, 2005, Attner et al, 2010, Roe et al, 2010 and Driver et al, 2012)

9. The Christie NHS Foundation Trust
The relationship between cancer and dementia?
Continued…
Mortality rates
•8.5% with no dementia died within 6 months
•33% with dementia died within 6 months (Raji et al, 2008)
•Pts without dementia lived 4½ years post diagnosis
•Pts with moderate / severe dementia, just 8 months (Robb et al, 2009)

10. The Christie NHS Foundation Trust
The implications of hospital admissions
• Hospital stays = poorer outcomes
• Longer inpatient stays
• Increased chance of discharge to institutional care
• Worsening of dementia symptoms
• Higher mortality rates
(Alzheimer’s Society, 2009)

11. The Christie NHS Foundation Trust
How can dementia complicate treatment?
• Impaired capacity
• Difficulties understanding implications of illness
• Failed appointments
• Reduced ability to follow treatment plans
• Under-reporting of treatment-related symptoms
• Reduced ability to self-care
• Carer’s put under increasing strain

12. The Christie NHS Foundation Trust
Case Study – Mrs Mary Quant
•Cognitive impairment
•Lives alone
•Supportive son and daughter in law
•Retired Beautician
•62 year old lady
Admitted - Non Hodgkins Lymphoema
•Partner passed away
6months earlier

13. The Christie NHS Foundation Trust
Mary
• 62 year old lady
• Referred to the Christie for treatment of NHL
• Decision to treat with 6 cycles of chemotherapy

14. The Christie NHS Foundation Trust
Concerns
• Very poor short term memory.
• Frail-underweight
• Lived alone- concerns non compliance of treatment and
consent to treatment
• Request for Mental Capacity Assessment in relation to
decision to treat
• What shall we do?

15. The Christie NHS Foundation Trust
Interaction
• Admitted- Quiet, co-operate, pleasant but isolated as no-one spoke
to her due to her limited conversation. Not eating well. Would get
lost on ward. Staff made aware of why this happening.
• Encouraged to go to dayroom to eat- appetite improved. Familiar
objects encouraged by bed and staff encouraged to engage with
her.
• Conversations would include her role as beauty therapist. With this
she would become very animated and alive. Staff brought in bridal
magazines for her to look at.

16. The Christie NHS Foundation Trust
Interaction
• Staff began to see Mary as a unique individual rather than a patient
with a dementia, they started to enjoy each others company and had
more interaction. Staff became protective of her.
• Words became unimportant it was the interaction and valuing of her
as a person.
• I began supporting/educating family and encouraged them to think
about the future.

17. The Christie NHS Foundation Trust
Interactions
• I sat with Mary - she slept on and off and was amazingly when
awake very animated and her conversation flowed
• We “people watched” and she made comments about the nursing
staff “ ooh isn’t she nice”
• She appeared comfortable and content
• Spoke of her life and said “ I’ve had a good life, I’m tired now”
• I cleaned her nails and massaged her hands. She asked if she
could have moisturiser on face and I thought what the heck.

18. The Christie NHS Foundation Trust
Outcome
For Mary
• Well being promoted
• Improved quality of Life
• Enhanced Care
• Recognised Person hood
and seeing her as an
unique individual with her
own needs
• Promoted communication, not
always verbal
Carer
• Felt Supported
• Education
• Planning for future
• Addressed Psychological and
emotional needs
• Chance to talk

19. The Christie NHS Foundation Trust
Outcome
For Nurses
• Satisfaction
• Education through action
• Communication
• Support
• Recognised Need
• Person Centred Care
• Holistic
• Importance of sharing and
gathering information
• Reflection
Myself
• Change Practice
• Multi professional working
• Palliative Approach
• Education
• Action and supporting nurses
• Screening and assessment
• Appropriate discharge
arrangements

20. The Christie NHS Foundation Trust
In summary
.
•Although people with cancer have dementia they must be given the
opportunity for treatment- however discussions are vital from referral
and should be on-going throughout treatment
•People with dementia can live with quality in their lives until they take
their last breathe. With good care we can help them achieve that

21. The Christie NHS Foundation Trust
Finally
• “ You matter because you are you. You matter to the last
moment of your life, and we will do all we can, not only to
help you die peacefully, but also to help you live until you
die”
Simard J ( 2013) The End of Life Nameste
Care Programme for people with Dementia.
Health Professionals Press