1. What if the patient wants answers... (and you don’t have them) Dr Geraldine Swift and Dr Sonia Mangwana

2. Case Example 1 A 38 year old businessman has a seizure at work. He was previously fit and well with no history of epilepsy. His GP sends him for a CT head which reveals a fronto-temporal lesion. He is referred to oncology. He is highly anxious. He married within the last year, and has a daughter of 10 months. You see him with the oncologist, who confirms he has an inoperable glioblastoma multiforme.

3. Case example 1 continued He will be having chemotherapy and radiotherapy. The oncologist tells him his prognosis is 12-18 months. He sees you in the waiting room after the appointment, saying that he knows the doctor said something about a poor prognosis, but he cannot remember any more. He asks you, ‘Am I going to die?’

4. Case example 1 continued How do you feel? What does the patient feel? What do you do? What is the consequence of this?

5. Case example 2 Dorothy is a 72 year old lady with colorectal cancer. She had the tumour surgically excised 2 years ago and was doing well, but has now been readmitted with symptoms of bowel obstruction and fatigue. Upon admission she informed the consultant oncologist and the ward nurses that she does not want to be told anything about her condition.

6. Case example 2 continued She wants all discussions regarding investigations, results, treatment options, and prognosis to be had with her husband Harry, not her. She has asked Harry only to tell her what decisions he makes, but not to explain to her anything about her chances. Harry is agreeable to this, wanting to do whatever minimises her distress. Investigations have confirmed advanced disease plus liver metastases. Her prognosis is poor, and treatment now palliative. Harry asks you, ‘How long has she got?’

7. Case example 2 continued How do you feel? What does the patient feel? What do you do? What is the consequence of this?

8. Case example 3 A 40 year old primary school teacher is diagnosed with small cell lung cancer. She is attending for out- patient chemo, to be followed by radiotherapy. She is distraught. She is tearful and angry. She tells you that she has always prided herself for her healthy life- style; she has never smoked, she looks after her diet, she cycles to work every day, and she rarely drinks alcohol. This does not make sense to her, she cannot accept it, its totally unfair. She demands, ‘How could this have happened to me?’

9. Case example 3 continued How do you feel? What does the patient feel? What do you do? What is the consequence of this?

10. Case example 4 A 46 year old man is diagnosed with advanced prostate cancer. Some years ago he went to see his GP with frequency and poor stream. GP checked PSA and told him it was normal, suggested symptoms might be due to anxiety. He felt foolish and did not go back although symptoms persisted. On direct questioning oncologist tells him PSA was borderline. If a follow-up PSA had been taken, his disease would probably have been curable. He is angry and bitter and worries that his premature death will leave his family without financial support. He asks you, ‘Will you support me in sueing him?’

11. Case example 4 continued How do you feel? What does the patient feel? What do you do? What is the consequence of this?

12. Case example 5 A 40 year old woman has advanced breast cancer. She has been intensely anxious since diagnosis a few months ago. She had a scan yesterday to assess the effects of treatment and is due to come back for results in 3 days. You know the scan shows a good response. She comes down to the out-patient department and asks you: “Can you tell me anything at all about the results or get someone to tell me? I cannot sleep or eat and I feel like I’m going mad!”

13. Case example 5 continued How do you feel? What does the patient feel? What do you do? What is the consequence of this?

14. What if the patient wants answers…. General discussion Learning points Tips

15. Thank you!