CASE SCENARIO – Presentation Helena presents at her GP surgery with worsening abdominal pain

You are presented with two case studies, each of which has five questions.

Your answers must be evidence-based to demonstrate and support your clinical decision-making. You should consider your strategy for management from the perspective of a clinical nurse specialist in palliative care.

CASE SCENARIO 1: HELENA

Presentation Helena presents at her GP surgery with worsening abdominal pain. The pain is mainly localised to the right upper quadrant of her abdomen and can vary in nature, but for the past 2 weeks has been present most of the time. It has prevented her from sleeping for the past 3 nights, and she feels exhausted.

Past medical history

Helena is 68 and retired as a bus driver five years ago. One year ago she was found to have a large abdominal mass, which was found to be an ovarian carcinoma. It was found to have spread throughout her peritoneal cavity at presentation and therefore a palliative treatment regimen was started. Despite chemo/radiotherapy, she developed widespread intraperitoneal lymph node involvement. A recent CT-scan showed four separate small masses in her liver, likely to be metastases. Recent blood tests including liver and renal function have been normal. She has been taking two co-codamol 30/500 tablets four times a day, but they only had a limited effect. She has tried NSAIDs but cannot tolerate them as they give her severe epigastric discomfort.

On examination

She is not jaundiced but does look very tired. Her abdomen is distended and on palpating her liver the GP notes that it is enlarged. The area around her right upper quadrant is very tender, but there is no guarding or rebound tenderness.

Questions 1&2

Helena has been taking two co-codamol 30/500 tablets four times daily. What would you discuss with her about next steps specifically regarding pain management options? If you were to consider an opioid, what decisions would you make in terms of an appropriate prescription?

When you mention the word morphine, she flinches and says “Oh no!” What would you discuss with her?

A further issue.

She has a lot of questions about morphine, including how often to take the medication and when to take breakthrough doses. She also wants to know what side effects to look out for.

 Question 3

What would you do to provide her with more information and what issues may arise for her?

And now…

Helena returns 2 days later and says that the pain control is working reasonably well, but that she is finding taking regular oral immediate-release morphine every 4 hours cumbersome. She says she has read the leaflets and would like to consider a sustained-relaese preparation.

Question 4

What would you do?

And finally…

She returns several weeks later. Her sustained-release morphine has been titrated up to 30 mg twice daily and she is taking four additional doses of immediate-release morphine 10 mg as rescue doses for her breakthrough pain. Despite this, she remains in pain. She has also found that she is seeing shapes and figures appear and disappear.

Question 5.

What action should you take? 

CASE SCENARIO 2: JANE

Presentation

Jane is a 67 year-old single woman with a history of vulval cancer and evidence of metastases to the lungs, hypercalaemia and a pulmonary embolism. She has one sister, Sandra who lives close by but has had a challenging relationship with her sister in the past so contact is infrequent.

Past medical history

Jane was diagnosed following admission to hospital following a fall where routine bloods show a raised calcium level, multiple cavitating lesions in both lungs and a large blood clot in her right lung

On examination

Jane is in pain (groaning and restless), confused and disorientated. She is a poor historian and unable to answer your questions.

Question 1

What should your management approach be, both from a pharmacological and non-pharmacological perspective?

Next steps

You revisit Jane in hospital after 3 days and she remains confused and agitated despite blood results showing that her calcium level is now within normal range. She is crying and tearful and screams if anyone touches her. Ward staff advise that she is taking her medication as prescribed but ‘ it does not seem to be working’.

Question 2

What changes would you make to her medication at this point? The clinical staff on the ward proposes that a syringe pump may provide better pain relief. What would you advise?

A further issue…

Jane has now been transferred to the local hospice. She remains symptomatic despite your interventions. There is increasing evidence of vulval excoriation and ulceration and any procedure or nursing intervention is distressing. The only member of the team who seems to be able to engage with Jane successfully is the chaplain.

Question 3

What changes, if any, would you propose for her clinical management? Why might the chaplain appear to be able to engage more successfully with Jane than other members of the multidisciplinary team?

And now…

As her pain remains relatively unresolved, a nerve block is proposed. This would necessitate a removal the local hospital and Jane is frail. Another option would be a trial of ketamine. The team is unsure which decision to make and seek your advice.

Question 4

What decisions would you need to take into account in deciding the best option for Jane?

If you decided to choose a ketamine trial, what clinical considerations are needed in terms of prescribing, administration and evaluating the effect of the medication?

And finally…

Jane eventually settled and died peacefully. She was never fully pain-free and the ward staff remained concerned that this meant she did not have a ‘good death’. They ask you to lead a case conference to discuss the clinical decisions made regarding the care and management of Jane.

Question 5

What important messages would you need to give from a palliative care perspective to the team regarding the holistic management of Jane’s care planning?