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Case history

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Image not available. A 56-year-old woman presented to her GP with a 10 day history of frontal headache in the context of orthodontic work. She then developed mild confusion and left facial droop over a 3 week period. On her third GP visit, she was referred to the emergency outpatient neurology clinic (normally seen within days), after discussion with the neurologist on call. During the weekend, she was referred to A&E by an out-of-hours GP, with worsening symptoms. She was diagnosed with frontal lobe glioblastoma and underwent surgery, chemotherapy and radiotherapy. The overall treatment intent was palliation and symptom control.

After hospital discharge, a follow-up GP appointment was scheduled to explore her understanding of the diagnosis, prognosis and treatment plan. She had one daughter of early adult age and a husband with multiple sclerosis who lived in a nursing home. She was issued a Med 3 fit note (i.e. sickness certificate) for 2 months initially and encouraged to explore her employment options with her employer.

A lead GP was assigned to the patient, who was also added to the practice multidisciplinary team (MDT) discussion list. Active cancer treatment was promptly communicated to primary care through frequent clinic letters. She responded well to the chemoradiotherapy and had no recurrence until 16 months after diagnosis. When disease progressed, the neuro-oncology MDT team decided that it was not in her best interest to undergo further systemic therapies due to bone marrow suppression from the second line chemotherapy.

The decision to stop all treatments came as a shock to the patient, who had had 16 months of relatively normal life. She was referred to the local hospice. She was visited and supported by the palliative care nurse, who explored the patient's worries about her only daughter (who was at university), assisted with applying for disability allowance (form DS1500) and provided regular updates during the monthly practice MDT meeting. A lasting power of attorney was set up. Joint home visits with the GP and palliative care nurse were arranged. Dosette boxes and twice daily social care were arranged, while input from the occupational therapist and district nurses was also sought.

In the subsequent 2 months, the patient developed a head droop and shuffling gait. A do-not-resuscitate order was signed after discussion with her and her health and welfare attorney. 'Just-in-case' medications were delivered. She was subsequently admitted to the hospice for symptom control, following two focal seizures and increased agitation, and passed away peacefully a month later.

How did the patient's presentation affect her diagnostic pathway and time to diagnosis?

What was the role of her GP in providing patient-centred care?

What were the roles of the palliative care services in providing holistic and integrated care?

How did integrated care play a part in the management plan?

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How did the patient's presentation affect her diagnostic pathway and time to diagnosis?

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