Table 1

Four clinical cases to illustrate the challanges of cancer care during the COVID-19.

Case	Challenges	Responses	Lessons learnt
Madam A	Madam A, 73 years old, with metastatic stomach cancer on conservative treatment. Poor appetite; very time consuming for her relatives to feed her. Later admitted for haematemesis and anaemia. Condition stabilised post transfusion. One week after admission had sudden coffee ground vomiting and died. Her relatives were shocked. During the hospitalisation, relatives were not allowed to visit. They questioned if her death was from poor care in the hospital and suspicious that it was due to starvation from feeding difficulty.	To address the concerns, a meeting with oncologist, palliative care doctor and nurse was arranged with Madam A’s relatives and bereavement counselling offered. Relatives were encouraged to talk and express concerns. We regained trust by active listening and demonstrating empathy. Medical notes were reviewed. Information about Madam A’s death given. Communication gaps, misunderstandings and negative feelings were sorted and settled.	Normally, relatives receive update from the healthcare team during visiting hours. Relatives who could not accompany patients at the end of life have complex emotions. Regular updates of patients’ conditions to relatives are essential; especially under restriction, for example, updating by phone calls alternate days. Guidelines should allow more flexible visiting for end of life. For example, relatives must declare any travel history outside Hong Kong or respiratory symptoms before visits; have temperature check before entering; limit number of visitors each time and so on.
Madam B	Madam B, a 96-year-old woman, was admitted for colon cancer complicated with intestinal obstruction and needed total parental nutrition. It was her first hospital admission ever. Unfortunately, she became confused a few days later due to the unfamiliar environment and no visiting from family members.	Investigations (including CT brain, blood tests) were done promptly to exclude reversible causes for confusion. After settling the acute problem, she was referred to palliative care. The confusion improved after transfer to the palliative care unit where relatives were allowed.	Family member reassurance and comfort was the best medicine. Normally relatives accompany older patients even in the acute hospital. Referral to palliative care less urgent and sometimes delayed. In the COVID-19 period, no visitors allowed. Settling acute problems efficiently and early referral to palliative care/rehabilitation facilitated family support and this practice should be continued in future.
Mr C	Mr C, a 76-year-old man, had radioactive iodine refractory thyroid cancer and multiple lung metastases. He was admitted for acute renal impairment and pneumonia and needed antibiotics. He was in low mood with poor appetite. This was the deepest separation from his family in his life.	We encouraged Mr C’s relatives to use video calls to communicate with him. We educated him on using an iPad. Video conference calls between Mr C, his relatives and clinical psychologist provided remote psychological support.	Even normally relatives may not be able to visit the patients often because of their busy work or schedule. A call from relatives can certainly comfort the patient and show their care. Use of technology, for example, video calls or telemedicine should be promoted as this can definitely improve the communication between patients, caregivers and healthcare professionals when direct contact is not feasible.
Mr D	Mr D, a 85-year-old man, with lung cancer with multiple lung, bone and liver metastases. He failed three lines of systemic treatment and was on conservative treatment. He was admitted to our oncology ward for bone pain and received palliative spinal radiotherapy. After this, his condition deteriorated day by day. He was dying. Visiting based on compassionate ground—with maximum two people—was allowed. Relatives expressed wish to stay with him throughout.	We introduced them to advance directive and raised the possibility of ‘dying-at-home’. Relatives understood the legal procedures and logistics and took Mr D back home. Two days later, he passed away peacefully with close relatives beside his death bed. Relatives were grateful for the arrangement.	Many people in Hong Kong do not accept the concept of dying-at-home. Some even worry if someone dies at home, the price of the apartment will depreciate. Nevertheless, with option of being able to accompany their loved ones, advance directive and home care should be promoted to provide alternative to families.