1. Recognising illness in the Terminal Stage Mr Aali Sheen 10 th October 2015

2. Who am I? Consultant General Surgeon Hepatopancreatobiliary specialist Abdominal wall and Hernia Medical school 1993 Trained in London, Leeds and Manchester Appointed Consultant in 2005 Undertaken 450 Liver/GB; 101 Pancreas resections for cancer

3. Introduction Diagnosis of cancer is not always easy Cardinal signs Soft signs Can always be missed Cased based scenarios –Straightforward –More difficult in interpretation

4. Early symptoms Generally feeling unwell ‘Not Right” Haven’t been the same Going on for a few months Occasional tummy pain but nothing serious But I was eating fine up until last week

5. Cardinal symptoms Weight loss Abdominal discomfort Poor appetite Altered bowel habit PR bleeding DysphagiaOdynophagiaHaemoptysis

6. Signs Increasing age Recent change in lifestyle Thin (not always) CachecticJaundiced Abdominal distension Lump – SJ nodule

7. How can we tell?

8. Case 1 69 year old man Likes his drink Noted tummy swelling Feels otherwise ok Eating plenty Thought he should come and see you?

10. Tests?? Ultrasound? Routine serum investigations Cancer pathway Immediate referral to Specialist and Cancer MDT Tumour markers – can be undertaken in hospital

13. Hepatoma History predicts problem Diagnosis often late Cirrhosis Options for cure are limited –Surgery if Childs A –TACE –Ablation –Chemotherapy

14. Case 2 35 year old patient mother of three Feels awful Jaundiced ! Bilirubin – 275 Admission to Hospital – don’t take no for an answer – Call the Consultant

17. Investigations Relief of Jaundice failed with ERCP Tight distal bile duct stricture ? Stones Percutaneous drain inserted – could not bypass stricture – is this malignant? Patient deteriorating Died 30 after admission

18. Diagnosis Malignant cholangiocarcinoma – on a background of choledochal cysts Poor overall prognosis Take home message Very high Bilirubin! It’s ok for a transient rise but not to a very high level

19. Case 3 55 year old lady with UC complained of a low Hb Investigated with colonoscopy – no tumour Gastroscopy normal Bloods show a mild anaemia No obvious other abnormalities What next??

20. Blood film Bone marrow Abdominal imaging Ultrasound –Dilated ducts on the left lobe only –Normal LFTs CAT scan ?

21. X-sectional imaging showed possible PSC Segmental cholangiocarcinoma is a worry Needs surgery Chemotherapy not ideal for this cancer Surgery undertaken – patient well

22. What to look out for? Unexplained weight loss Bleeding – Vomit/PR/PV Persistent heartburn or indigestion Altered bowel habit JaundiceHaempotysis Breast Lump Abnormal persistent lump

23. Terminal Cancer Review care needs and goals of care with resident (if able), family and GP Implement palliative care plan or pathway Ensure care given is in line with previous direction from the resident, if they are now unable to give direction Manage symptoms appropriately Withdraw treatments, activities, medication that are no longer appropriate or benefiting the resident Provide counselling and support, to the resident, family and staff.

24. Three triggers ! The Surprise Question "Would you be surprised if this patient were to die in the next few months, weeks, days'?" General indicators of decline - deterioration, increasing need or choice for no further active care Specific clinical indicators related to certain conditions (unresolving jaundice).

25. Guidance Three case scenarios 69 year old woman with terminal cancer 84 year old with deteriorating medical condition 91 year old lady with chronic condition

26. GSF guidance A – Blue –Diagnosis – Stable with a year + prognosis B – Green –Unstable, Advanced disease C – Yellow –Deteriorating, weeks prognosis D – Red –Terminal care, final days NAVY After care

27. Change in Patient’s status Weight loss (more than 10% of body weight in last 6 months); BMI below 18 Serum albumin less than 25g/l General physical decline; dependent in ADL’s, bed / chair fast Multiple diseases impacting on wellbeing Increased frequency of admissions to acute care.

28. End of life Prepare family for passing away Unexpected when it finally happens Painful for all involved Try not to expect them to know to much information – as all the information they have received may not have ‘got through’ Best to let them ask any questions ?

29. Summary High index of suspicion Severe abnormality in blood tests should raise alarm bells Increasing age is important but younger patients usually present late with advanced disease - If in doubt please refer on Triggers Preparation for death is never easy

30. Useful Links NICE –http://www.nice.org.uk/guidance/cg27/chapter/guidan ce Macmillan –http://www.macmillan.org.uk/information-and- support/diagnosing/how-cancers-are- diagnosed/signs-and-symptoms/signs-and- symptoms.html Cancer research UK –http://www.cancerresearchuk.org/about- cancer/cancer-symptoms

31. Thanks to HCA Clare Evans www.manchestergeneralsurgery.co.uk www.manchesterherniaclinic.com