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Palliative cancer care - general issues - Management
How should I assess and manage the person's physical symptoms?

  • Assessment of the person's needs for physical support should be repeated at key points during the course of the illness, including:
    • At the time of diagnosis.
    • Around treatment episodes.
    • As treatments end.
    • At the time of a relapse.
    • When death is approaching.
  • As symptoms are often multiple and interrelated, a systematic approach to assessment and management is necessary. The following is suggested:
    • List symptoms, assess their severity, and prioritize them with the person.
    • Diagnose the cause of symptoms as accurately as possible.
    • Elicit the person's understanding of the diagnosis.
    • Set goals for treatment with the person and their carers.
    • Review and reassess changing symptoms regularly.
    • Keep nutrition and hydration status under review.
Clarification / Additional information
  • Enquire about symptoms, rather than waiting for the person to report them [Regnard and Tempest, 1998].
    • Determine the impact of each symptom on the person's life by enquiring about time of onset, exacerbating factors, effects on everyday life (e.g. sleep disturbance).
    • Even if cancer is the underlying cause, different mechanisms may be responsible for the symptom (e.g. vomiting from hypercalcaemia or gastric outflow obstruction).
    • Bear in mind that all symptoms may be made worse by insomnia, exhaustion, anxiety, and depression.
  • Keep drug treatment as straightforward as possible [Twycross and Wilcock, 2001]:
    • Do not delay starting treatment, as symptoms become more difficult to manage the longer they are left untreated.
    • If a symptom is persistent, regular prophylactic treatment is preferable to the use of drugs on an 'as required' basis.
    • Achievable goals should be discussed and agreed with the person.
  • Nutrition and hydration provided by tube or drip are regarded in law as medical treatments and should be treated in the same way as other medical interventions. They would usually be considered of overall benefit if the aim is to prolong life and/or provide symptom relief [GMC, 2010].
  • Refer to a specialist if a problem occurs which is outside the expertise of the primary care team [Twycross and Wilcock, 2001].
Basis for recommendation
  • This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004], expert opinion from the literature based on clinical experience [Regnard and Tempest, 1998], and the General Medical Council guidance for doctors, Treatment and care towards the end of life: good practice in decision making [GMC, 2010].
  • A qualitative study found that doctors tend to underestimate the severity of symptoms (e.g. dyspnoea), and this is associated with under-treatment of those symptoms [Roberts et al, 1993].

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