CASE STUDY TWO
Mrs Bloggs is an 84 year old lady who lives alone at home with two carers four
times a day and family support. She has known metastatic bowel cancer. She is
mainly bed-bound but transfers with a full-sling hoist to a chair and commode.
She has no cognitive deficits. The GP has been called by one of her carers as
she had a cupful of bright red blood in the commode after opening her bowels
this morning. The carer has informed the GP practice that Mrs Bloggs has a
PACE document.
Discuss possible next steps.
Notes from From PACE Document:
3.0 Main diagnosis:
Myelodysplasia previously Blood transfusion dependent
Bowel Cancer managed conservatively
Liver and Bone metastases
Increasing frailty
3.4 Discussion summary regarding End of Life Care
This was discussed with Mrs Bloggs and both her daughters in a family meeting at the RSCH with members of the ward
MDT present. Mrs Bloggs has become increasingly frail now spending most of her time in bed. She tires easily and this
does not seem to be helped by blood transfusion. Following admission with worsening mobility, scans have
demonstrated the extent of her metastases. She has expressed a wish to return home and for her on-going care to be in
the community if possible. Following discharge she does not feel the effort of coming up to hospital for further blood
transfusions will be beneficial, particularly as these have not helped her recently. She would consider a hospice if her
care could not be managed at home. On-going focus is on symptom control, comfort and dignity. Mrs Bloggs is aware
that her prognosis is likely to be weeks to months but at this time has capacity to make welfare decisions.
3. 5 Spiritual needs of the patient at the end of life: Nil specific
3.6 Preferred place of death
1
Home
Patients name
4.0 Assessment
Possible Developments specific to the person Action Category Comments
(see 4.1 below) Please also see supplementary notes for
care
e.g.“chest infection”
(e.g.” Hospital” home staff (appendix 2)
or “Home”)
e.g. “oral antibiotics appropriate”
1
Increasing breathlessness, chesty cough Home
At high risk of developing pneumonia
related to immobility. Consider oral
antibiotics if feverish or unwell.
Morphine may help with symptomatic
breathlessness
2
Lethargy and drowsiness
Home
This may be related to progressive
anaemia. Further transfusion is unlikely
to be of any benefit.
3
Vomiting or bowel distension
Home but
consider
Hospital
Vomiting may be helped by
haloperidol. Consider enema for
constipation. If symptoms worsen
consider bowel obstruction and hospital
review.
4
Rectal bleeding
Home
Bleeding from bowel cancer is not
uncommon. Tranexamic acid can slow
rate of bleeding.
5
Serious unexpected event eg
Fall and broken bone
Hospital
Hospital assessment and management of
pain
6
Patient has no signs of life.
Home
Has DNAR form in place
4.1Action categories
Intensive:Transfer to hospital for treatment if appropriate. Intubation, ventilation etc. should be considered.
Hospital:Transfer to hospital for treatment if appropriate.
Home:Treatment, medication and comfort measures with support from GP.
Comfort:Palliative Medication by subcutaneous, oral or per rectal route, positioning, wound care and other measures to
relieve suffering. Admission to hospital would be avoided unless comfort measures fail (e.g.: fractured neck of femur).
2
Patients name