John is a 65 year old gentleman сurrently living at home. He is a widower and has two children, George, who is married with two children aged six and ten, and lives locally and Angela, who is single and lives in Germany. George visits his father every day. Angela visits every 1-2 months.

John had enjoyed good health until his late fifties. His only рast medical history had been treatment for a duodenal ulcer at age 45, which resрonded well to helicobacter pylori treatment. He did not take any other prescribed medication at that time. In July 2016, John developed a persistent respiratory tract infection and his GP arranged for a chest x-ray. The chest x-ray findings demonstrated a 5cm right upper lobe mass with a number of satellite lesions. The findings were highly suggestive of a primary lung malignancy with metastases throughout both lung fields. John’s GP discussed the findings with him in the presence of George and Angela.

Following discussion and deliberation, John made an informed decision not to pursue further investigation or interventional treatment. He explained that he had a life-long dislike of hospitals, had enjoyed a ‘good life’ and that he wished to focus on quality of life and spend his remaining time living as independently as possible in the residential facility. He said that he had a strong religious belief and he looked forward to meeting his wife again in Heaven. He said that he did not feel that the benefit of extending his life would be worth the burdens of hospital appointments and side effects of treatment. He preferred the idea of ‘letting nature take its course’ and felt that he was ready to die ‘when God calls’.

Three months later, John’s condition has begun to decline. He has lost half a stone in weight, and is more fatigued and nauseated. He has complained to George of a pain in the front of his leg, worse on walking and a dull ache at rest. He also has low backache. He is gradually become more breathless and has noted some haemoptysis. John declines hospitalisation. He agrees to Out-Patient x-ray and blood tests. The x-rays show widespread evidence of bone metastases in long bones, pelvis and lumbar vertebrae. They show progression of lung disease- there is evidence of right upper lobe collapse and the lung metastases have all increased in size. The blood tests show a normochromic, normocytic anaemia of 10.3 g/dl, reduced albumin of 28g/L, elevated alkaline phosphatase of 223U/L but all else is normal (i.e. normal renal, hepatic profile and calcium; normal WCC and platelets).

John is currently maintained on MST 15mg BD and morphine sulphate instant release (Oramorph) 5mg PRN for breakthrough pain.

The GP makes a referral to the community palliative care team. You, as a palliative care doctor/clinical nurse specialist, are asked to meet with John and the family to address his physical symptoms using a palliative care approach.

Questions
1. Discuss the importance of impeccable symptom assessment in promoting enhanced quality of life
2. Discuss how you might support John in managing his symptoms.

Guidelines

As a palliative care specialist, you are asked to assess the John and devise a plan of care tailored to meet his needs within a palliative care context.
You are required to write a 2000 word case analysis which reflects the assessment and management of symptom(s) using a palliative care approach. The case study essay must:
1. Explain the purpose of the assignment, outlining the fundamental issues that you plan to discuss
2. Explore the principles of impeccable assessment to demonstrate an understanding of the holistic palliative care philosophy; integrating, psychological, social and physiological factors in assessing, planning and intervening in the relief of symptom(s)
3. Appraise the literature, evidence based tools and related theories of symptom management to guide practice, arrive at clinical decisions and manage symptoms effectively.
4. Discuss the importance of providing individualised care tailored to meet the needs of the patient and their family