Transcript Knowing What to Communicate

‘What’ to communicate –
knowing ‘how’ isn’t enough
Dr Fiona Randall
Consultant in palliative medicine
Case 1
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A frail elderly man with inoperable
oesophageal cancer extending down into the
stomach, with a stent in situ, became SOB
and had a CTPA to look for PEs at the
oncologist’s request. No chemo options and
no surgical options re tumour.
CT showed a PE
Warfarin was started.
What information should this pt be given?
Case 1: should pt be told
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About the risk of bleeding?
About morbidity/mortality of PE?
About comparative ‘ways of dying’?
Should his view be sought re warfarin?
NB: warfarin isn’t drug of choice here
That consultant physician disagreed with
oncologist re CTPA and Rx of PE?
Case 1: outcome
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Patient was not, apparently, given information
re bleeding risk by oncologist when warfarin
started, but did know it was advised by the
oncologist
He was informed of bleeding risk by palliative
medicine consultant later.
He had a haematemesis, after which he
refused further warfarin.
Case 2
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A lady in her late 60s was found to have
widespread metastases (liver, lung, bone,
adrenal) from cancer of unknown primary
(likely ovary or breast on histology)
Severe fatigue, in bed all the time, symptoms
for 6 months
Commenced on chemotherapy: what
information ought this lady to have been
given?
Case 2: should pt be told
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That the likelihood of response to
chemotherapy with unknown primary is only
around 30%?
That therefore 70% of patients get side
effects and no benefit?
That her performance status (spending nearly
all time in bed) would normally preclude
palliative chemotherapy?
What gain a ‘response’ might mean?
Case 2 cont’d
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CT brain scan was normal pre-chemo
But later double vision developed (VI cranial
nerve palsy)
MRI brain:base of skull mets, no brain mets,
to see oncologist re RT
Husband asking for more info, concerned
about pt’s deterioration.
What should be communicated to him?
Case 2 cont’d
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The patient had started chemotherapy, hair
falling out rapidly,
said to clinical psychologist that she was glad
that hair was falling out as this ‘meant that
the chemotherapy is working’.
It actually means no such thing.
Should the patient’s misunderstanding be
corrected? If so, by whom?
Case 3
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A 70 yr old man was found to have bladder cancer,
no metastases, treated with L ureteric stent for
obstruction of L kidney, then RT.
CT scans 3 months later showed large liver mets in
R lobe of liver, small lung mets, all asymptomatic
and
Renal function deteriorated, R nephrostomy
inserted, L ureteric stent in situ and
He was hospitalised for ischaemic R foot due to
arterial thrombosis. Toes blue & cool.
Case 3 cont’d
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Pt was told that bladder cancer was inoperable, and
about poor renal function for which urologists were
not planning to intervene. Urea 25, K 4.9, eGFR 22
Vascular surgeons advised Warfarin after initial
heparin infusion (for improving foot). INR 1.2 prewarfarin. Not for vascular surgery.
Pt lived alone, still ran a business and keen to sort
out things with his clients ‘over a few months’.
What info should this patient be given about Rx now,
and as part of advance care planning?
Case 3:should pt be told
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That there was low likelihood of warfarin
restoring circulation?
That warfarin might cause bleeding (bladder
tumour + liver mets)?
That LMW heparin is contra-indicated due to
renal failure?
More about life expectancy (time)?
About likely progress of ischaemic foot and
symptoms from it?
Case 3: should pt be told
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That as renal impairment worsens he is likely
to lose capacity so
Should you explain the options for advance
care planning (advance statement, ADRT,
LPA appointment)?
That the doctors caring for him think renal
failure is a better end than infection due to
ganrenous foot?
Case 3: outcome
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Patient was transferred to EMH
Warfarin was discontinued on the grounds
that risks exceeded any foreseen benefit
(after D/W surgeon at SMH)
Pt died of renal failure within 1 week, and
before foot went frankly gangrenous.
Pt with capacity for the decision: Consent
process, GMC para 5
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‘The doctor and patient make an assessment of the
patient’s condition, taking into account the patient’s
medical history, views, experience and knowledge.
The doctor uses specialist knowledge and
experience and clinical judgement, and the patient’s
views and understanding of their condition, to
identify which investigations or treatment are likely
to result in overall benefit for the patient.’
GMC: consent para 5
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‘The doctor explains the options to the
patient, setting out the potential benefits,
risks, burdens and side effects of each
option, including the option to have no
treatment.
The doctor may recommend a particular
option which they believe to be best for the
patient, but they must not put pressure on the
patient to accept their advice.’
GMC: consent para 5
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‘The patient weighs up the potential benefits,
risks and burdens of the various options as
well as any non-clinical issues that are
relevant to them. The patient decides
whether to accept any of the options and, if
so, which one. They also have the right to
accept or refuse an option for a reason that
may seem irrational to the doctor, or for no
reason as all.’
GMC: sharing information
‘How much information you share with patients
will vary, depending on their individual
circumstances’
 ‘the nature of their condition,
 The complexity of the treatment, and
 The nature and level of risk associated with
the investigation or treatment.’
GMC: obligations re info
‘You must [my italics] give patients the information they
want or need about:
 The diagnosis and prognosis
 Any uncertainties about the diagnosis or prognosis,
including options for further investigations
 Options for treating or managing the condition,
including the option not to treat
 The purpose of any proposed investigation or
treatment and what it will involve
GMC: obligations re info
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‘The potential benefits, risks and burdens, and the
likelihood of success, for each option; this should
include information, if available, about whether the
benefits or risks are affected by which organisation
or doctor is chosen to provide care
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Any treatments that you believe have greater
potential benefit for the patient than those you or
your organisation can offer.’
GMC: what if pt declines info?
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‘No one else can make a decision on behalf of an
adult who has capacity.’
‘If, after discussion, a patient still does know want to
know in detail about their condition or the treatment,
you should respect their wishes, as far as possible.
But you must [my italics] still give them the
information they need in order to give their consent
to a proposed investigation or treatment.’
If they decline basic information, it might mean their
consent is not valid; they must be told this.
GMC: withholding information
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‘You should not withhold information
necessary for making decisions for any other
reason, including when a relative, partner,
friend or carer asks you to, unless you
believe that giving it would cause the patient
serious harm. In this context ‘serious harm’
means more than that the patient might
become upset or decide to refuse treatment.’
Advance care planning
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When discussing with a patient what treatment or
care they think they would/would not want in the
event of loss of capacity (an advance care planning
discussion, possibly resulting in an advance
statement)
They will need virtually the same information as re
consent.
What info should they be given re location of care
options, during illness and at death?
Patient lacks capacity for the decision:Best
Interests process
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As stipulated in the Mental Capacity Act, the
decision maker (usually health care professional)
must make a decision based on the patient’s Best
Interests
In seeking the relatives’/friends’ views re what
patient would have wanted and pt’s best interests,
relatives’/friends will need the same information as
the patient would have needed to consent.
Info shared on basis of patient’s best interests, but
remember confidentiality to patient.
Now, back to our cases….