Assessment and management of patients with advanced cancer involve physical, cognitive, psychosocial and spiritual aspects. A holistic approach would ensure that the aim of care is achieved. Much of the assessment would require the physician to spend time with the patient, asking relevant open-ended and specific questions, listening to the related as well as seemingly non-relevant answers. Effective communication skills will point us towards the hints and signals that the patients give away.
Physical management involves symptom control – pain, difficulty breathing, dryness of mouth, early satiety, as well as the ulcers and wounds as direct results of the tumour itself, side effects of medications or from the disabilities caused by the cancer. Since many of the patients need to be treated with opioids and steroids, careful approach need to be taken when starting, maintaining and counselling the patients about these drugs. Education need to be given to each patients to encourage them to manage their symptoms, learn about the drugs they use and undo the stigma that comes with those medications. There is still much to do in terms of training physicians regarding their use and safety as well.
Advanced cancer affects the cognition and mental capacity of a person in many ways. Patients may have metastatic brain lesions, hepatic encephalopathy, uraemia, hypercarbia, acidosis, anaemia or simply lethargy or depression. Even when the disease is incurable, and the solution of many of the above is “treat the underlying cause”, there are much to be done to control those symptoms.
It is an art to be able to draw a line between searching aggressively for the cause of symptoms, and controlling the symptoms, without compromising patient’s quality of life. This makes it useful for future physicians to have early exposure to palliative medicine, as this is a skill needed in practice, especially in General Medicine when it’s too easy to list down a line of investigations despite the patient being terminally ill.
It is also an essential skill to be able to make it clear patient’s loved ones why certain investigations and procedures are not carried out, as they may not be of patient’s best interest at that point of time. It takes a combination of sound knowledge in medicine, genuine concern for the patient and good doctor-patient-family relationship. Despite all the years in palliative medicine, I still am pleasantly surprised on how much understanding some patients and their families have on death, dying and futility; at times with more comprehension than the average physicians themselves.