Advanced Cancer of the Breast - Case Study Example

Palliative Care: Case Stud Introduction Despite advances in the field of medicine, there are many conditions which do not have treatment and eventually take a miserable course to death. One such condition is advanced cancer of the breast in which no medical or surgical treatment can cure the condition or prolong life. Patients with this condition develop many symptoms which cause great discomfort and despair not only to the patient but also their dear ones. The only solace to such patients would be to provide a comprehensive care which takes care of the physical, psychological, emotional, spiritual and religious needs of the patients so that they lead a peaceful life until their death. Such a care is known as palliative care. In this project various aspects of palliative care will be discussed which are individualised and tailor-made to a 85 year old patient by name Lora with advanced breast canccer in terminal stages. Assessment-1 Compose a care plan that has the specific needs of Lorna and her familys needs met appropriately. Lorna is in the terminal stages of advanced Breast cancer. She has gone through mastectomy and chemotherapy, but in vain. At this stage what she requires is palliative care. The aim of palliative care must be to relieve the patient of suffering, promote function of the patient, deliver help to meet the daily living needs of the patient, provide psychosocial support to the patient and also the family of the patient and clarify goals of care and associated treatments. The objective of palliative care in Lora must be to support her to live as actively as possible until she is alive, help the family members cope with their illness of their loved one and prepare them for death of Lora. The four cardinal principles of palliative care are non-malificence, beneficience, patient autonomy and justice. These principles need to be applied in the perspective of respect for life, acceptance of the fact that death is inevitable, provision of treatments which take care of the ongoing suffering, striving to preserve life only as long as life is not a burden and beyond that only asserting life, and also individual needs and that of the society (National Cancer Control Programme, 2005). Currently, Laura has has increased pain, chest swelling and progressive weakness. She has also developed a decline in her cognitive ability. Her chest swelling is uncontrollable as is her pain at present. Thus, the corner stone of palliative care in Laura would be pain relief. The pain management in her must be guided by the cancer pain management protocols. The analgesic ladder approach of pain managment by the World Health Organisation (WHO, 2009)is an useful guide to managment pain in Lora. According to this approach pain in Lora must be first tried to be controlled with paracetamol or non-steroidal anti-inflammatory drugs like ibuprofen. These drugs must be given round the clock, every 8 hours. A combination of paracetamol and ibuprofen also can be used. Side effects to thse drugs include gastritis, gastric ulceration and bleeding, liver dysfunction and enal dysfunction. these drugs are hence ot advisable in these conditions. When hese drugs cease to be effective, the analgesics of the next step on the ladder must be chosen. These analgesics are mild opiods like codeine (WHO, 2009). Even these must be administered ound the clock. Common side effects to these drugs are tolerance, nausea, constipation, drowsinness, sleep disturbances and confusion. Intolerance to side effects or ineffectiveness in pain relief is an indication to either change the type of analgesic used, or use a combination of analgesic or step up the analgesic in the analgesic ladder. The most powerful analgesic in the third and last step of the analgesic ladder of WHO is the high opiod analgesics like hydromorphone, morphine and fentanyl (WHO, 2009). These drugs can be given as a combination with drugs of the other steps. These drugs too have side effects similar to mild opiods. One of the methods to prevent or decrease side effects would be to change the type of drug once in every few days. the baove treatments are useful only for the localised chest pain related to swelling. These medications are seldom useful in bone pains which occur due to metastases. For bone pains, Lora should be treated with oral biphosphonates like clodronate, pamidronate and zoledronic acid. oral biphosphonates have been studied widely and clinically proven in breast cancer metastases (Poznak, 2002). Pharmacotherapy may not deliver complete pain relief to Lora. Thus, in combination with these medications, Lora will need non-pharmacological pain management too. There are many types of non-pharmacological pain managment techniques. the most widely used are transcutaneous electrical nerve stimulation or TENS, hot and cold water treatment, therapeutic massage and exercise (Menefee and Monti, 2005). Since most of the times, pain in terminal illness patients is associted with many other psychoemotional symptoms, psychological interventions also must be provided keeping in view holistic perpective of chronic pain. Lora may have depression, anxiety, fear, psychological distress and mood disturbances. The fear encountered is mainly fear of disease progression and painful death. Various psychological interventions which may be useful in Lora are cognitive-behavioural interventions and behavioural interventions (Zaza and Baine, 2002). Also, along with these, the patient must be provided cancer education, hypnosis and other imagery-based treatment interventions and training in coping skills. Educational interventions must be aimed to help Lora understand assessment of pain so that barriers to the treatment of pain are overcome (Keefe, Abernethy and Campbell, 2005). Education and training must als be delivered to caregivers and family memebrs to increase the psychological and social dfunctioning of Lora (Keefe et al, 2005). The pain management in Lora must be guided by pain assessment tools. There are many pain assessment tools available. Since Lora has mild cognitive imapirment PACSLAC or Pain Assessment Checklist for Seniors with Limited Ability to Communicate is an useful tool for pain evaluation (SIGN, 2008). Other than pain managment, other sumptoms also need to be taken care of. Abdominal pain can be managed with H1-antagonist pantodac. To relieve any constipation, dulcolax can be given. Insomina can be managed with benzodiazepines like alprazolam. The unresolving pneumonia needs immediate and constant medical intervention and assistance in the form of intravenous antibiotics, chest physiotherapy and steam inhalation. The swelling in Loras chest is due to lymphoedema. This should be managed with regular skin care, exercise, external support in the form of bandaging, massage and regular monitoring (National Cancer Control Programme, 2005). Other than medical management, nursing care, personal care bathing, dressing and taking to toilet, diet also must be planned and delivered. The plan must also include appropriate fluid intake, diet intake and dietary fibre intake. Lora must be given the type of food she relishes. In case she is not able to eat on her own, she must be fed. In advanced stages when she cannot swallow, she must be fed through nasogastric tube (National Cancer Control Programme, 2005). Other aspects which need to addressed in nursing palliative care plan are oral hygiene like brushing, care of dentures, mouth wash, prevention of oral thrush and preventive dryness and maintaining skin care like bathing, hair care, nail care, pressure sores care, etc (National Cancer Control Programme, 2005). Assessment-2 How would you demonstrate a palliative care approach when caring for this client? Palliative care is “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (WHO, 2009). Palliative care in Lora must be delivered through a team approach so that each and every need of the patient and her family shall be addressed. Also, the care plan must be based on the clinical picture, the spiritual and cultural needs of the patient, the desires of the patient and the wills and wishes of her loved ones. Palliative care is a team driven care approach. Palliative care is possible only through integration of the physical, emotional, social, psychological and spiritual aspects of life. In Lora, palliative approach is brought about by addressing all the medical needs like pain, pnuemonia and cognitive impairment, her physical needs like hearing problems, her psychological and spiritual needs like religion and prayers. Describe the importance of teamwork in this specialised area. The main caregiver in Lora is the nursing staff because she is in a residential facility. The activities of the team are coordinated by the primary care physician. Other team members include hospice physician, nurses, home health aides, social workers, clergy, trained volunteers, and other therapists like speech, physical and occupational therapists. The team outlines individualized medical and support services which includes nursing care, personal care like bathing, dressing and taking to toilet; physician visits, social services and counseling (NHPCO, 2008). The team also decides on the tests and procedures to be done on the patient, the medicines and other treatments to be given and the required medical equipment that should be around the patient (NHPCO, 2008). The ultimate aim of the team is high-quality comfort care (NHPCO, 2008). The staff of hospice care is specially trained to assess, anticipate, treat and prevent certain physical symptoms which are the root cause for distress and discomfort. Pain management is the most important aspect of hospice care. The staff of the hospice care coordinates with the treating physician and makes sure that all medicines, treatments and procedures aim to keep the patient comfortable and pain-free. The staff continuously evaluates and monitors the effects of these therapies (NHPCO, 2008). Hospice staff also provides bereavement care for surviving family members. This care is provided by trained volunteers, clergy members or professional counselors (American Cancer Society, 2008). Who else participated in the development of the clients nursing care plan? The nursing plan is mainly based on the physial and mental needs of the patient and this will be developed after discussion with various members of the team, with the main coordinator being physician. The family members also need to be involved in drawing up the nursing care plan. Nurses play an important role in palliative care of Lora. Since they closely work with her, they are in a position to provide constant personal, emotional and spiritual support. They also have an important role in the assessment and monitoring of management of Loras pain and other symptoms. Nurses can be the first persons to evaluate pain and then can advise the treating physician whether the pain remedy advocated was appropriate. Nurses can also evaluate the effects of the medications prescribed after Lora uses the medicines. Nurses must be aware of the WHO ladder for chronic pain management. They must also be aware of drug-drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When Lora reports side effects, the nurse must record, manage and monitor the symptoms, guide physician about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as coordinators of different specialities by educating Lora about the dosage of the drugs and the need for good pain control (Delphi Study, 2007). How would you support clients and others to contribute to the care plan and identify their preferences for spiritual, cultural, needs and lifestyle options? Palliative care aims to enhance the quality of life and influences the course of the illness in the most positive sense. The care can be initiated in early stages of illness in conjunction with other medical, chemotherapeutic and surgical interventions which aim to prolong life. This form of care adapts the interdisciplinary practice and the philosophy of hospice care and applies it to the severely sick patients irrespective of their prognosis. Palliative care is also independent of whether the patient chooses to continue curative or life-long treatments (Meier, 2002). Addressing spirituality is an essential part of treatment of cancer patients (Taylor, 2006). This is because, spirituality is the basic needed of each and every individual through whom the individual looks for meaning of his or her life. Pain in cancer affects the spiritual aspect of the individual (National Health Service, 2006) and increases fear of death, loneliness and discomfort. The religious aspect of the patient may be taken care of by taking her to church as much as possible or by asking some one to read bible for her or by asking a priest to meet her. Spiritual care is possible by gauging the depth of despair, distress and anger, supporting all her decisions, offering her to discuss her problems without inhibitions and by showing concern to all her interests like ceremony after death and preparing wills (National Cancer Control Programme, 2005). Good quality of life can be maintained by allowing Lora to lead as much normal life as possible, by facilitating her to indulge in enjoyable activities, by making her feel that she is still wanted and by providing her opportunity, space and time to spend time with her partner, children and grand children (National Cancer Control Programme, 2005). What support would you provide to the client and their family members to prepare for the clients death? The family should be involved in decision making. They should be explained about various treatments and informed consent must be taken before instituting any therapy (National Cancer Control Programme, 2005). According to Mok and Chiu (2004), "Trust, the achievement of the goals of patients and nurses, caring and reciprocity are important elements of nurse–patient relationships in palliative care." Nurses stay with the patients through their journey of illness to death. Thus, it is easy for them to connect to patients and establish a relationship with them. Only by establishing such a relationship will the nurses be able to deliver the best possible care and meet the levels of satisfaction of the patient. By establishing a trustworthy relationship, nurses can provide a base to prepare Lora and her family members to death. According to Mok and Chiu (2004), "involvement represents encounters that emphasize the importance of being concerned, interested and giving." Actions of care, appropriate attitudes and trustworthiness not only establish a connectedness with patient, but also help in the improvement of physical and emotional state and help them go through the journey of death with peace. The family members must be therapied to come to terms with the fact that their loved one will be leaving soon. They should be allowed to see and talk to Lora as much as possible. The family members must not be allowed to see distressing things like restlessness of patient, intravenous lines and changes in the color of the skin (National Cancer Control Programme, 2005). How do you maintain the clients dignity after their death? In a stage when there is day-to-day deterioration and it appears that death can happen any time, holistic patient comfort and care must be ensured by managing symptoms, giving minimal drugs, upholing her wishes, alleviating anxiety and fear, addressing her religious and spiritual needs and by telling her that her family is around (National Cancer Control Programme, 2005). Dignity is another issue which needs to be addressed in palliative care. Due to heavy reliance of the patient on the nursing staff and other caregivers, the sense of dignity in Lora can get eroded. Thus it is utmost important to maintain dignity in palliative care. There is no clear-cut definition for the concept of dignty. Though there have been many definitions for dignity, the main theme in all definitions from a nursing perspective has been respecting a person as a person (Hall, Longhurst and Higginson, 2009). In one study, the researchers identified 3 main themes of dignity, namely, the unrecognisable body, fragility and dependence and inner strength and a sense of coherence. Dignity-oriented care provision can be applied by using many models, the most appropriate one for end-of-life being Chochinovs dignity-conserving model. This model was actually developed after analysing the interveiews with various cancer patients pertaining to what supports their dignity and what undermines it. Conservation of dignity is implied basically through addressing issues pertaining to illness, dignity conserving repertoire and also addressing various social aspects of the experience of the illness. The psychological and spiritual distress of Lora can be reduced by promoting sense of dignity through psychotherapy. Dignity can also be elated by allowing Lora to do as many activities as psoobile on her own. Treating Lora with respect is another approach to dignity. The patient should be made to feel that she is worthy of gaining respect and being treated with dignity (Hall et al, 2009). Conclusion Nurses play a major role in the provision of palliative care to patients with terminal cancer stages. An understanding of various aspects of care and having a right attitude which builds trust and establishes a relation with the patient and her family members is essential to help the patient spend her last days in peace and in pain-free manner. References American Cancer Society. (2008). What is Hospice Care? Retrieved on 29th October 2009 from http://www.cancer.org/docroot/ETO/content/Eto_2_5x_What_Is_Hospice_Care.asp Delphi Study. (2007). WHO Normative Guidelines on Pain Management. Retrieved on 29th October 2009 from http://72.14.235.132/search?q=cache:XaoHa1yWUgkJ:www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf+Delphi+Study.+(2007).+WHO+Normative+Guidelines+on+Pain+Management&cd=1&hl=en&ct=clnk&gl=in Hall, S., Longhurst, S., and Higginson, I. (2009). Living and Dying with Dignity: A Qualitative Study of the Views of Older People in Nursing Homes. Medscape Today. Retrieved on 29th October 2009 from http://www.medscape.com/viewarticle/710065 Keefe, F.J, Abernethy, A.P., Campbell, L.C. (2005). Psych.ological approaches to understanding and treating disease-related pain. Ann Rev Psychol., 56, 601 –630 Meier, D.E. (2002). When pain and suffering do not require a prognosis: Working toward meaningful hospital-hospice partnership. Innovations in End-of-Life Care, 4(1). Retrieved on 29th October 2009 from www.edc.org/lastacts Mok, E. and Chiu, P.C. (2004). Nurse–patient relationships in palliative care. Journal of Advanced Nursing 48(5), 475–483 Menefee, L.A., and Monti, D.A. (2005). Nonpharmacologic and Complementary Approaches to Cancer Pain Management. Journal of American Osteopathic Association, 105(5), 15-20. National Cancer Institute. (2009). Pain. Retrieved on 29th October 2009 from http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/healthprofessional National Cancer Control Programme. (2005). Manual for Palliative Care. http://www.whoindia.org/LinkFiles/Cancer_resource_Manual_5_Palliative_Care.pdf National Hospice and Palliative Care Organisation (NHPCO). (2008). Caring Connections. Retrieved on 29th October 2009 from http://www.caringinfo.org. Poznak, C.H.V. (2002). The Use of Bisphosphonates in Patients With Breast Cancer: Palliative Bone Pain Therapy. Medscape Today. Retrieved on 29th October 2009 from http://www.medscape.com/viewarticle/447549_7 Scottish Intercollegiate Guidelines network (SIGN). (2008). Control of pain in adults with cancer. Retrieved on 29th October 2009 from http://www.sign.ac.uk/pdf/SIGN106.pdf Shaw, S.M., (2006). Nursing & Supporting patients with chronic pain. Nursing Standard, 20(19), 60-65. WHO. (2009). WHOs pain ladder. Retrieved on 29th October 2009 from http://www.who.int/cancer/palliative/painladder/en/print.html Zaza, C., Baine, N. (2002). Cancer pain and psychosocial factors: a critical review of the literature. J Pain Symptom Manage., 24, 526 –542. Read More