you are the medical junior doctor working on the oncology day unit

Mr Chris Thomson, a 28-year-old single man with newly diagnosed stage 4B Hodgkin’s
lymphoma, is about to start six cycles of intravenous chemotherapy of Adriamycin
(doxorubicin hydrochloride), bleomycin, vinblastine and dacarbazine(ABVD), given as an
outpatient on day 1 and 14 of each 28-day cycle.
The patient has already been given written information concerning the treatment, including
the Cancer BACUP booklet about Hodgkin’s disease and summary information about ABVD
chemotherapy covering the drugs that are used, how the treatment is given, how often
treatment is given, and the possible side effects.
The information provided states that with no treatment the patient is likely to die in weeks
or months; that with the treatment proposed the chance of surviving 5 years is 70 –80%
(with the possibility of high-dose chemotherapy and peripheral stem-cell transplant in the
event of relapse); and that the most significant side effect of chemotherapy is vulnerability
to infection.
you are asked by the chemotherapy clinical nurse specialist to obtain
written consent.

 Before you examine, treat or care for competent adult patients you must obtain their
consent.
 The main issues here are to establish competence to consent, and to explain the
benefits and risks of the treatment proposed or of other courses of action.
 Adults are assumed to be competent unless demonstrated otherwise.
 If you have doubts, the question to consider is: can this patient understand and weigh
up the information needed to make this decision?
 Unexpected decisions do not prove the patient is incompetent, but may indicate a
need for further information or explanation.
Patients need sufficient information before they can decide whether to give their
consent (in this case, the benefits and risks of chemotherapy).

Is the patient competent?

Can he or she understand and weigh up the information needed to make the decision?

An unexpected decision does not mean that the patient is not competent.

 Does Mr Thomson understand the key issues, ie prognosis without treatment,

prognosis with treatment, side effects of treatment, and possibility (or lack) of
alternative treatments?
 the aim of this treatment is to cure you of the disease.
 With this chemotherapy, your chances of surviving for 5 years are
probably around 70–80%.
 Furthermore, even if the disease were to come back, it is often still
possible to cure Hodgkin’s disease using high-dose chemotherapy
and peripheral stemcell transplantation – that is a sort of bone-
marrow transplant using your own cells.

 if you have no treatment for your Hodgkin’s disease, then I’m afraid
that there’s no doubt that it will continue to grow and spread, and
will lead to your death.
 This is likely to occur within weeks or months.

 the ABVD chemotherapy regimen is given by injection through a

flexible plastic tube into the vein, with you being treated as an
outpatient every 2 weeks for 24 weeks.
 Before each cycle a blood test is performed to ensure that it is safe to
give the chemotherapy.

 it may be possible to tell simply by examining you, for instance if the

swollen glands that we can feel get smaller, or we may repeat the CT
scan after 2–3 months of chemotherapy, which will tell us more about
the swollen glands inside your chest and abdomen.

 chemotherapy often causes unwanted side effects and it is difficult to

predict who will develop these.
 Some people are lucky and get very few side effects whilst others have
a rougher ride.
 Many possible side effects can happen and some are more common
than others.
 I will tell you about the more common ones and will give you a written
patient information leaflet that describes them in greater detail.
 If you have any questions, either before you start the treatment or
during the course of therapy, then please ask me or one of the
nurses.

 yes, that is one of the possible side effects: your ability to father a
 child may be affected by the chemotherapy.
 You should already have had the chance to store a sperm sample so
that if your fertility is affected then it can be
 used for you to have a child in the future, but if you have not done so
then we can make arrangements.
 However, despite this, you must not assume that because you are on
chemotherapy you are not fertile.
 It is important that you do not father a child whilst on the
chemotherapy because the drugs could affect the growing baby.
 It is important that you use effective contraception whilst on the
chemotherapy and for at least a few months afterwards.

 the most important thing to be aware of is that chemotherapy lowers

your resistance to infection.
 If at any time after starting the chemotherapy you get a high
temperature (over 38°C or 100.5°F), feel hot and sweaty or shivery, or
you suddenly fell unwell then you must contact the hospital oncology
team right away.
 This is the most important thing because it may happen to you when
you are at home and it is something that you have to deal with.
 I have written down all the ways to contact us any time, day or night.
 If you cannot get in touch with us, come straight to the Accident and
Emergency Department and explain that you are a patient on
chemotherapy.

 if you do get an infection you will be admitted to hospital, have blood

tests and other tests taken to find out the cause of the infection, and
be given injections of antibiotics into your veins.
 This normally settles things down within a few days or a week.

 yes, I am afraid that they can, but this isn’t likely.

 They usually settle with antibiotics and other treatments, but it’s true
that sometimes they can get very bad.

Further comments
 Excellent patient information is available for cancer patients from resources such as
CancerBACUP(www.cancerbacup.org.uk) and these should be provided for all patients
as part of the informed consent process.
 In addition all cancer patients should have a ‘key worker’ who helps to coordinate
their care pathway and is usually their first point of contact.
 All patients starting chemotherapy must be provided with instructions on how to
access the oncology team in the event of an emergency at any time of the day or night.