Essential areas of cancer care include prevention (e.g. smoking cessation), early diagnosis including screening where appropriate (to provide the best chance of curative treatment), breaking bad news in a sympathetic, supportive and motivational manner, maintaining empathy and support, and the optimum management of the specific cancer.

Primary care management of people with cancer

Patients may be seen periodically by oncologists and/or other relevant specialists. However patients need a great deal of support from primary care, which may include:

• Providing realistic information - which may be very positive in view of many cancers being curable if diagnosed in the early stages.
• Providing empathy and support to patients and their carers in coping with chronic illness.
• It is essential to address all concerns and fears. Many patients will have a preconceived fearful outlook when diagnosed as having any cancer.
• Provision of advice or access to advice regarding any medical issues not covered or forgotten while being seen in secondary care.
• Management of associated psychological difficulties, including anxiety and depression.
• Evaluation and treatment of symptoms in the context of possible association with the cancer or an unrelated presentation.
• Evaluation and management of side-effects resulting from medication or other treatment.
• Provision of financial information, including exemption from prescription charges and relevant benefits.

Terminal care

The process of caring for people with cancer in the last year of life includes:¹

• Identifying requirements for palliative care and supportive care.
• Assessment of the patient's needs, symptoms, preferences and any issues important to them.
• Planning care around the patient's needs and preferences and enabling these to be fulfilled, including supporting patients to live and die where they choose. Improved advance care planning and information leads to less fear, fewer crises and fewer admissions to hospital.

All aspects of the person's needs should be considered and addressed. As well as health, psychological and social issues, this will also include issues of nutrition, consent to treatment, any advance directive and any applicable benefits for the terminally ill patient. Essential principles in the delivery of end of life care include:^1,2

• Choices and priorities of the individual are at the centre of planning and delivery.
• Effective, straightforward, sensitive and open communication between individuals, families, friends and workers underpins all planning and activity. Communication reflects an understanding of the significance of each individual's beliefs and needs.
• Delivery through close multidisciplinary and interagency working. Close communication and co-ordination improves confidence and effectiveness of care. Continuity of care must include out-of-hours provision.
• Individuals, families and friends are well informed about the range of options and resources available to them to be involved with care planning.
• Care is delivered in a sensitive, person-centred way, taking account of circumstances, wishes and priorities of the individual, family and friends.
• Care and support are available to anyone affected by the end of life and death of an individual. Carers must be fully supported, informed, enabled and empowered.
• Control of symptoms: see separate articles on Pain Control in Terminal Care, Dyspnoea in Palliative Care, Controlled Drugs and Syringe Drivers.
• Health and social care professionals must be fully supported to develop knowledge, skills and attitudes.

The Liverpool Care Pathway for the dying patient³

• The Liverpool Care Pathway (LCP) for the dying patient provides an evidence-based framework for the delivery of appropriate care for dying patients and their relatives in a variety of care settings.
• The LCP was developed for use in hospitals but can be used in other care settings.
• The specialist palliative care teams lead the training for LCP. Once implemented, the LCP empowers generalists to care for the dying and can be transferred to non-cancer patients.
• The LCP encourages a multi-professional approach to the delivery of care that focuses on the physical, psychological and spiritual comfort of patients and their relatives that has also been shown to empower generic staff in the delivery of care.

Audit

The Qualities and Outcomes Framework (QOF) for 2009-2010 includes 2 indicators for palliative care (each worth 3 points):

• The practice has a complete register of all patients in need of palliative care or support irrespective of age.
• The practice has regular (at least 3-monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.

Regular audit should be considered for any aspect of palliative care, e.g. frequency of review, identification of main carer, multidisciplinary discussion, referral and medication issues.