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Acute admissions in cancer care: a crucial point of transition and intervention

Published: 12 October 2021

In this blog Ash Lillis outlines the current challenges for professionals and patients when handling acute admissions and what needs to change to improve the patient journey and experience. It is becoming clear that an acute admission to hospital is a crucial point of transition for people living with cancer when we should be thinking about having conversations about future plans for treatment. 

Ashing Lillis

Ash Lillis National Clinical Adviser for acute medicine, Macmillan Cancer Support

Setting the scene

For people living with cancer, having to go to hospital as an emergency is challenging and often low point in their cancer journey.  People have told us “it was the worst time in all of my treatment” and “I’d do anything not to go back to A&E” . Nonetheless, with more people being treated longer for cancer and the increasing prevalence of cancers and multi-morbidity in their lifetime, it can be hard to know when and how to have conversations around future wishes for end of life care. But the question remains: when do we have those discussions?

We already know that having a cancer diagnoses as an emergency is linked to a poorer experience, less chance of being well enough for anti-cancer treatment and high chance of moving into end of life care rapidly after diagnosis. However, in those living with incurable cancer or cancer and multi-morbidity/frailty this can also be a time of transition into the last months of life. 

What does the data show?

People with cancer who must access unplanned care are at a high risk of dying within the next year.

Data from Merseyside and Wessex shows that if a person with cancer (or diagnoses with cancer at admission) becomes acutely unwell and have cancer as a diagnosis there is a 70% chance that will not be alive 12 months later. To most healthcare professionals (HCPs), this is much higher than they would have expected, but do we normalise the need to access urgent care rather see it as a significant transition point in their cancer journey?

Are we overestimating the likelihood that those people who are sick enough to need admission to hospital will improve to a point they will be well enough for systemic anti-cancer treatment. In fact, an analysis of data from people who died from cancer in 2015 in Northern Ireland showed that 30% of people who died of cancer died during their first emergency admission and 74% of people who died of cancer had at least 1 emergency admission in their last year of life

What is happening

We are failing to recognise that an acute oncology admission is a point of transition for many PLWC
We need to recognise that an acute admission is telling us as HCPs that our patients' needs, and prognosis are likely to have changed and it is time to have a conversation about what matters most to our patients - hoping for the best but planning for the worst. 

If we do not start these conversations and recognise the palliative care needs of a patient following an acute admission 12 months before death data from Midhurst shows they are 50% more likely to die in their preferred place of care. Data from Northern Ireland indicates identification of a transition to palliative care is not happening with a third of people had ≥3 admissions in there last year of life. The data from Merseyside does not breakdown what stage of cancer or specific co-morbidities, but what does come across is that older people with ‘treatable’ cancer have as poor a prognosis as those who have cancer diagnosed as an emergency admission.

Where do we go from here?

Advance care planning is everyone’s job but prognostication in end of life care is more complex than ever. The data above shows that the population of PLWC who access urgent care are those most need of that conversation so if we, as the HCPs who provide this acute cancer care, concentrate on having these conversations we are likely to meet the needs of those approaching the end of their life.

It is more important than ever to build professional confidence in having difficult and challenging conversations, therefore Macmillan’s Professional Knowledge and Development team have created a blended course of learning on Courageous Conversations

As a clinician thinking about how we can best support people with cancer who become acutely unwell I now think about the 3 steps we can take:

  • See it - recognise acute admission as point of transition in cancer journey with high risk of needing EOLC.
  • Say it - communicate this with the person living with cancer and their family and have a conversation about what matters to them. 
  • Share it - record these wishes and ensure they can be seen by all professionals involved in their care. 
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