Pre Treatment Clinic

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• Pre - Treatment Clinic
• January 2005 to April 2006
• Kate Reid, Zoë Neary, Desmond McGuire
• University Hospital Birmingham NHSFT UK

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The Reality

• .
• Only seeing patients at the extremes of a
  continuum
• Dysphagia/public speakers
• Anxiety/distress
• Extreme weight loss-re feeding syndrome.

Team members aware of patients but only being
referred the very needy.
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Preparation and Development July 2004

• Described a random 10 patients pathway
• Discussed when we should see them and why we
  wanted to.
• Discussed with surgical colleagues.

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The aim of a service

• Create a service that has meaning to a
• patient group
• Offers useful resources to them at different
• stages of their treatment programme,
• recovery and follow up

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The aim of a service

• Satisfaction with the information given leads to
  better quality of life and reduced
  anxiety/depression
• (Fallowfield et al 1994 British Medical Journal)
• Vast majority of patients with cancer want
  specific information, clinicians tend to under
  estimate the information needed. (Jenkins et al
  British Journal of Cancer 2001
• Patients want information on the impact of the
  treatment different options available.
  Inadequate information is associated with
  increased anxiety and psychological difficulties.
  
• (Edwards British J of Max Facs Surgery 1998)
• How do we make systems flexible to patient
  diversity whilst they are making decisions?
• (Ziegler et al2004 European Journal of cancer
  care 2004)

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NICE Guidelines

• Careful assessment of each patients clinical,
  nutritional, psychological state is crucial to
  inform treatment planning.  MDTs should
  therefore establish multi-disciplinary
  pre-admission clinics at which all aspects of the
  case can be considered by appropriate
  specialists, and members of the MDT can discuss
  the way forward with individual patients and
  their carers.
• Improving Outcomes in Head and Neck Cancer
• Nice 2004

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• Macmillan Clinical Nurse Specialist
• Clinical Nurse Specialist Nutrition
• Clinical Nurse Specialist Altered airway
• Dietitian
• Speech and Language Therapist
• Head and Neck Counsellor

In the Clinic January 2005
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What is the clinic for?

• Involvement in decision making Communication
• Discuss imagination vs. reality
• Realistic expectations
• Information check
• To build Trust /Familiarity
• Understand previous experiences
• Open expression
• reducing emotional distress
• Prioritise and pace information for the patient
• Coping Strategies
• Promote Personal Control

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Pre Treatment Clinic

• Full assessment of all factors that will
  enhance or undermine the patient and familys
  ability to cope with the treatment programme and
  the disease.
• High risk screening- like nutrition alcohol
  intake
• Requires attention to psychological and
  rehabilitation issues.
• Formation of intervention strategies to
  identified needs.
• Clinical management plan.

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Bad News Broken

• Existing concerns confirmed
• New concerns provoked
• Distress

• Gives advice reassurance
• Give information
• Check if person OK

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Immediate consequences

• Person preoccupied with undisclosed concerns
• Fails to take in information
• Selectively recalls negative information
• well give you radiotherapy to mop up any
  residual cells
• Remains distressed

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Longer term.

• High levels of emotional distress
• Development of anxiety disorder and depressive
  illness
• - high number of undisclosed concerns
• - perceived inadequacy of information
• Dissatisfaction with care
• - perceived inadequacy of information

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Broken Bad News

• Existing concerns confirmed
• New concerns provoked
• Distress

• Distress acknowledge
• concerns expressed
• Information needs established prioritised

• Gives advice reassurance
• Give information
• Check if person OK

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Attendance over 16 months

• Seen on the ward.
• Being referred in from another hospital.
• Treatment date overtakes pre treatment assessment
  date.
• Patient refuses. (5)

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Questionnaires Used June 2005

• Quality of Life general EORTC C30 version3
• Bjordal K et al Eur J Cancer. 2000
• Quality of Life disease specific EORTC HN 35
• Bjordal K et al Eur J Cancer. 2000
• Optimism scale Life Orientation Test
• Scheier MFet al Health Psychology 1985
• The Alcohol use disorders identification test 2nd
  edition Self Assessment
• Babor TF et al WHO 2001

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Hello, my name is England and Im a drinker
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Why raise the issue of alcohol

• Every unit which provides diagnostic services
  for Head and Neck cancer should follow documented
  guidelines on alcohol dependency assessment and
  management. (NICE, 2004)
• Improving Outcomes In Head and Neck Cancers
• November 2004

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(No Transcript)
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AUDIT
Low Risk
Hazardous
Harmful
Dependant
Information Leaflet
Advice Brief Intervention
Referral Detox Regime Vitamins
Advice Community Services
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AUDIT
Key __ advised re alcohol dependency
__ discussion re alcohol intake
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EORTC C30 and HNC35
Key __T1/T2 __T3/T4
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Key __HRQOL T1/T2 __T1/T2 QOL__HRQOL T3/T4
__QOL T3/T4
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Interventions subsequent to clinic

• Pain management
• Nutritional support
• Anxiety management
• Alcohol
• Smoking
• Dysphagia intervention
• Information

• Medication
• Supplements
• Intervention
• Intervention/withdrawal
• Advice and Referral
• Advice and exercises
• Contact details

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What we now know

• The patient and carers know the teams better, and
  we are not anonymous
• Disease stage should not exclude a patients
  referral
• Timing of pre treatment clinic can be varied
  according to team and patient need.

• Assessments are carried out in a systematic way
  to focus the team on clinical significance.
• Patients have to be seen as individuals rather
  than as a statistic.
• Team builds trust and gives support to patient
  and one another

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The Future

Maintain 90 seen at pre treatment. What are the
outcomes from the pre treatment clinic? How does
the intervention effect the patient/carers? How
does the information that we obtain alter our
management of the patient during their
treatment? Does it change lifestyle?
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• How doctors and nurses communicate can
  profoundly affect the psychological adjustment
  and quality of life of cancer patients and
  relatives
• Peter Maguire (1999)

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Thank You for Listening desmond.mcguire_at_uhb.nhs.uk