A 60-year-old man on the Respiratory Ward has recently been diagnosed with lung cancer. He has been told about the diagnosis, but feels it is too much to take in. He has asked you to talk to his sister because she used to be a nurse and understands things better. He presented with breathlessness 3 weeks ago and was found to have a pleural effusion. The pleural fluid was drained, and a CT thorax has revealed multiple small masses within both lung fields. Analysis of the pleural fluid has confirmed the histology to be small cell carcinoma. Your consultant has asked for an opinion from the Oncologists to consider a course of palliative chemotherapy.
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This is a breaking bad news scenario. The candidate should start by going over the patient’s current condition and exploring the relative’s current understanding of what is happening. The candidate should make a reference to confidentiality and state the patient has given him consent to discuss with relatives. The candidate should give a warning shot, eg ‘I have some bad news to tell you’. A good candidate will use time effectively. After delivering the bad news, the candidate should wait for the relatives to speak next. If too much time is passing, a prompt may be used, eg ‘I realise this is a lot to take in, take as much time as you need’. It should become obvious that the relatives have many concerns and the candidate should acknowledge this. The candidate should apologise for delays in diagnosis. In terms of the specific questions, the candidate should not give any cause for the lung cancer and say there are many causes.
The candidate was talking to the patient’s sister and therefore consent is needed for this discussion to take place. This was recognised by the candidate established early on. The candidate sensitively explored what the patient’s sister knew about his condition and got some background of how he had actually presented. The relatives concern regarding early diagnosis was handled well by the candidate. A potential missed diagnosis by a colleague is a common theme in the PACES communication encounters and must be handled professionally. No matter how emotionally charged the scenario becomes, remain calm and avoid the three Cs at all costs – namely Confrontation, Collusion, and Confabulation.
If your explanation was not accepted, then you should signpost the person to the appropriate route of complaining, which in this situation would be through the GP surgery. The candidate explained correctly that they would go to the patient and go through the information with him with the support of a Macmillan nurse. A lung cancer specialist nurse would be another option, and of course in some hospitals these will be the same person.
There was some jargon used here, such a ‘a small localised tumour’ and ‘more systemic’ when explaining surgery was not an option, which should be best avoided although the relative was a nurse do not assume her level of knowledge. A good communication point would be asking what type of nursing she did, which may give more information around her level of knowledge for a particular condition. The bottom line, however, is never assume and steer clear of medical terms that for doctors so easily trip off the tongue.
The candidate suggested this is not terminal and in the setting of small cell lung cancer affecting both lungs and fluid, I would suggest that whilst treatment will hopefully be available in the terms of palliative chemotherapy and possible radiotherapy, cure would not be possible. This does not necessarily have to be covered here but broached only if raised or appropriate.
The question of asbestos exposure and the link to cancer was raised by the patient’s sister. The candidate quite rightly said that it is mesothelioma that is caused by asbestos exposure, but it is also worth noting that asbestos exposure itself also raises the risk of primary parenchymal lung cancer which is usually non-small lung cancer. Small cell lung cancer, as stated is very closely linked to smoking. Lung adenocarcinoma is the lung cancer that can occur in non-smokers.