The American Society Of Cancer

Published Date: 02 Nov 2017

Greenlee, Murray, Bolden, and Wingo (2000, p.50) claim that pancreatic cancer remains associated with a very poor prognosis and a major cause of mortality despite the advances in technology. In the majority of cases by the time of diagnosis, the disease reaches an incurable state either due to metastasis or extensive local disease.

Mrs. Camilleri who is facing a terminal illness with a poor prognosis is a good candidate for palliative care. To better understand what palliative care is, one has to look at the definition of palliative care as given by the World Health Organization.

An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and the relief of suffering by means of early identification of pain and other problems, physical, psychosocial and spiritual (WHO 2002).

The care-plan devised for Mrs. Camilleri should be tailored for her and should reflect her needs as well as others supporting her (in this case her three sons and her husband). Palliative care should also be provided in a holistic approach, addressing physical, psychological and spiritual needs of the patient and should also be sensitive to one’s personal beliefs, culture and traditions (Baile et al, 2005). This process can be very complex and therefore there is a need for a multidisciplinary team. Although the family members as well as nurses might be in contact with the patient for the majority of the time, a multidisciplinary team is important since nurses may not possess all the skills required by the patient to deal with psychosocial problems and therefore may be inadequately prepared (Glaser and Strauss, 1965). A referral to a psychologist as well as a social worker might be ideal to provide the patient with a better care-plan. Good coordination between professionals of the multidisciplinary team can further provide the patient with a sense of continuity of care.

One should also consider in which setting the care is to be given. Mrs. Camilleri might be able to receive care on a home basis, outpatient-basis or in a hospital setting. The health-care professional must therefore take into consideration the setting as well as the resources available to provide the best care possible. In whichever setting, the patient must be in an environment in which she retains some kind of control and dignity and is given the necessary importance in decisions that affect his quality of life (Baile et al, 2005). The WHO also suggests that the patient should be allowed to live as actively as possible until death. Independence should be greatly promoted especially in the activities of daily living.

An important part of palliative care is to manage the symptoms and provide the necessary pain relief (WHO, 2002). It is also important to treat or prevent complications that might arise because of the treatment. Nausea and constipation can be a side-effect of treatment and with simple treatments such as anti-emetics and laxatives such distressing symptoms can be managed better. Pain should be regarded as a subjective feeling because although there are pain assessment scales that try to quantify pain, it is ultimately the patient who is experiencing pain and each individual has a different tolerance to it. It is estimated that although pain relief can be controlled in 85-95% of cases, poor pain management is still a problem (Lin, 1998). Pain can alter the way a person thinks and reasons and thus greatly influences the patient’s quality of life. The theory of Total Pain as suggested by the International Association for the study of Pain (ISAP) suggests that pain is multidimensional and it incorporates the physical, emotional and spiritual distress. The nursing role entails an assessment on all the dimensions since each dimension is interlinked with the other. Mrs. Camilleri might experience severe abdominal pain and although opioids such as morphine might reduce her pain, she might still be afraid of what is going to happen to her and might be feeling anxious or agitated as the illness progresses. Fear of the unknown as well as fear of death should be taken into consideration. Important information should be given to her and as the disease progresses she must be informed of what symptoms she might experience. (Further pain management shall be discussed in section B). It is important that one empathizes with her, provides comfort, and gives her time to process the information. Overloading the patient with too much information at a time can result in more anxiety and stress (Penson, 2000).

Trust and Comfort play a very important role in palliative nursing. Comfort can be given through good communication listening and continuous accessibility, while trust can be earned by allocating the appropriate time to the patient and being honest. It can be helpful to have a reciprocal relationship where sharing of experiences and thoughts take place from both sides. Attending to fine details of physical care and appearance is also crucial. According to Degner (1991) it is also important to respond appropriately and non-judgmentally towards misdirected anger from the patient and the family whilst trying to help the patient with her personal growth. In some situations one might consider referral or facilitate the provision of psychosocial care. The nurse should be there to advocate and represent the patient’s and family’s needs if the need arises.

The WHO suggests that palliative care should focus on care rather than cure and that the patient is given support. Death should be perceived as a normal and natural process of life. One should not try to hasten or postpone death. When the disease no longer remains curable, the treatments can cause the patient unnecessary distress and should only be continued if the benefits outweigh the burdens. Wilkinson (1996) states that stopping treatment doesn’t signify defeat. A change in perception is required. Mrs. Camilleri needs to slowly shift her perspective from dying from cancer to living with a terminal illness and thus gradually accepting the fact that she will eventually pass away. The bereavement nurse along with the social worker can help her set things in order and come to terms with her condition.

Another principle of palliative care is to set goals, hopes and aspirations for the patient as well as identifying the patient’s coping strategies. Setting goals doesn’t mean surviving cancer but a goal might be setting important things in order. Hope is another important factor. Instilling hope doesn’t mean finding cure for cancer but hoping to achieve the goals that were previously set and hoping to be able to overcome daily challenges thus serving as a daily coping strategy. It is important that the nurse affirms the patient’s self and family’s worth and treats the patient with dignity. Another helpful tool that can be used is to encourage the patient to keep a journal of thoughts and experiences so that she can later share her thoughts with a professional (Penson 2000).

Seale (2000) states that a good death has always been important to all cultures and if death is seen as a defeat it will not have a high priority, but if it is seen as the summation of all the care and efforts put together than it is the most important part of the care process. There is no such definition of a good death but Walter (2003) argues that a good death is one in which the patient has autonomy in his/her last days. Unfortunately according to Higgs (2000) the mentality is to cure till the last moments (prolonging suffering) at the patient’s expense because otherwise the health care professionals might feel helpless. Training health-care professionals to cope with the death and dying process can help one understand better what the patient wants and in doing so provides the patient with a better scenario of a dignified good death.

B. How would you assess and manage her current uncontrolled symptoms?

The pancreas is a pear-shaped glandular organ located in the upper abdomen and has an exocrine function as well as an endocrine function. The pancreas can be divided into a head, a body and a tail. Depending on the stage of the cancer and the site, symptoms and treatment options may vary. According to Ashley and Zinner (2007) approximately 70% of pancreatic cancers originate in the head of the pancreas. Cancer causes the cells to grow in an abnormal and poorly controlled manner, giving rise to tumors. The head of the pancreas is very close to the common bile duct and the duodenum and therefore tumors located in the head may block these structures, affecting their functionality and giving rise to symptoms and causing pain.

The American Society of Cancer (2013) suggests that treatment in metastatic (at which stage the cancer is inoperable) is a combination of radiation and chemotherapy. Gemcitabine and 5-Flurouracil are examples of chemo drugs that help to lower the cancerous growth and ‘shrink’ the tumor. The effectiveness of radiation remains very controversial. It is very important that a balance between the treatments and tolerance to treatments exist, since the side-effects of chemoradiotherapy are very severe. Nausea, vomiting, loss of appetite, hair loss, mouth sores and diarrhea are all side effects that need to be managed by the proper nursing interventions as will be discussed further on. These side-effects often stop as soon as the treatment is stopped.

Another important thing is that chemoradiation damages the bone marrow and therefore affects the production of blood cells. Patients with damaged bone barrow may have more risk of infections due to the decrease in white blood cell count. Bleeding may also be present due to the shortness of platelets, while shortness of breath and fatigue may be the result of a decrease in red blood cells. The nurse as well as the doctors may routinely take bloods so that any required transfusions may be given (American Society of Cancer 2013).

The International Association for the study of pain describes pain as an unpleasant emotional and sensory experience with actual or potential tissue damage. Although symptoms such as tachycardia, high blood pressure, dilation of pupils, vasoconstriction and insomnia are indicators of the pain, pain is whatever the patient says it is. The pain assessment should go beyond the physical symptoms and one should try to empathize and understand the emotional hurdles the patient is going through so that pain can be better managed.

Pain assessment should be a primary aspect in the care of Mrs. Camilleri. The goal is to enhance the quality of life of the patient by controlling pain and minimizing the side effects of the treatment. Pain affects the sleeping patterns as well as the general mood of the patient. According to Ruger (2000), a comprehensive assessment should include information from the patient about the onset of pain, location, quality (stabbing, shooting, dull or aching) and intensity. To help the patients better explain their pain, a numerical assessment scale can be introduced. Furthermore Ruger (2000) suggests that the health care professional should also assess the coping strategies of the patient and address concerns of the patient such as fear of addiction and side effects of the pharmacological interventions.

According to the University of Michigan (2007) good pain management leads to an increase in physical activity and well-being of the patient however there are some barriers to pain control. Amongst such barriers there is a lack of understanding about how to take the medications as well as concerns that pain may become incontrollable at a later stage if the medications are taken regularly.

The WHO (1986) states that the initial pain relief includes opioids such as morphine, antidepressants such as amitriptyline, anticonvulsants such carbamazepine and NSAIDS such as diclofenac sodium. These medications can be administered through different routes and come in the form of tablets, liquids, skin patches such as the Duragesic (fentanyl) patch or rectally in the form of a suppository. The best pain control strategy consists of both long acting pain medications as well as immediate release medications. Both medications can be administered via an intravenous and subcutaneous route (Ruger, 2000).

Long acting pain medications are administered irrespectively of the presence or absence of pain and on a scheduled and a regular basis. These medications work best if the schedule is not changed. Examples of such medications include Morphine and Fentanyl. Immediate release medications are considered as ‘Breakthrough pain medications’ and should be administered if the patient is still in pain after the long acting medications are given. Some examples of these opioid medications are oxycodone, hydrocodone and morphine immediate release. Breakthrough medication can be controlled via a PCA (patient controlled analgesia) pump, allowing the patient to have a sense of control in administering her pain medication. It is suggested that the patient keep a record of the breakthrough medications taken since such information can be helpful when relayed to doctors. If breakthrough medication is needed 4-6 times a day regularly and keeps the patient awake constantly at night then the nurse must advocate for the patient with the doctor for a revision of the long-acting pain medication (University of Michigan, 2007).

Derby & Portenoy (1998) state that constipation is very common in cancer patients since it is one of the side-effects of the medications and the reduction in physical activity. The effects of constipation can be a combination of hard-stools, bloating, excessive straining, increased gas, abdominal cramping and nausea. Nursing interventions should include education regarding the inclusion of fiber in the patient’s diet by means of vegetables, prunes or dates, increasing the intake of water and promoting physical mobility. Laxatives may be introduced with the medications as well as milk of magnesia. If constipation progresses other means such as phosphate enemas can be considered.

Eisenberg, Carr and Chalmers (1995) suggest that if the pain is still present, the next therapeutic step might be a celiac plexus nerve block (NCPB). This involves an injection of local anesthetic and alcohol into the nerve plexus in the abdomen and the pain sensation is stopped from reaching the nerves for a longer period of time. The effects of NCPB are only temporary and the approach is not intended to permanently damage the nerve cells. This intervention has its own risks because around 40% of patients suffer from orthostatic hypotension and diarrhea and therefore it is important that the patient compensates for the loss of water by increasing fluids.

In addition to medication, the University of Michigan (2007) suggests that other complimentary therapies can be included. Such therapies include relaxation through guided imagery, hypnosis, prayer, meditation, acupuncture and acupressure and therapeutic exercises. Although such tools are not enough to eliminate moderate to severe pain, studies show that they are very helpful when combined with medication.

According to Braines (1998) nausea and vomiting are common in approximately 21 – 68% of pancreatic cancer patients and there may be a series of contributing factors. Stress, anxiety, chemoradiation, medications (especially opioids and NSAIDS) and the delay of stomach emptying caused by the compression of the tumor on the duodenum are all factors that should be considered. Moreover the cancer itself affects the metabolism rate and the chemotherapy may cause some foods to taste different. Pancreatic insufficiency may also be present because the pancreas might not produce the necessary amount of pancreatic juices and digestion of food is incomplete. For all these reason weight loss is common pancreatic cancer patients.

Gastric outlet obstruction (GOO) is another factor that causes nausea and vomiting. In this case there is an obstruction in the pylorus and food remains in the stomach because it cannot pass into the small intestine. Lillmoe (1998) states that although only 19% of patients present with symptoms at the time of diagnosis, around 35% of the patients eventually develop malignant gastric outlet obstruction. To treat GOO a palliation surgery to remove the blockage is required but till the surgery is performed the patient should be hydrated with normal saline via an intravenous route and proton pump inhibitors should be given to the patient to reduce the acid reflux.

According to the University of Michigan (2007) the overall goal in nursing management should be to keep a stable weight. To achieve this goal, medications such as Benzodiazepines (ex. Midazolam), sedatives such as haloperidol and anti-anxiety medications such as Lorazepam might be administered to the patient via different routes. Some considerations should be taken because sedation doesn’t mean pain-relief and sedation may cause respiratory distress. Other tips which might be useful to improve diet and weight include eating small meals throughout the day and choosing foods that are high in proteins and calories. One can also try new foods regularly since patient might experience a change in taste. It can be helpful to avoid fatty or oily foods, avoiding spicy foods and lying down immediately after meals. Fluids in-between meals can be limited to avoid a feeling of fullness. Other alternatives include appetite stimulating medications such as Megastrol acetate. If required a dietician or nutritionist may be recommended to the patient for better management.

If the cancer affects the endocrine part of the pancreas the patient might also experience an onset of Diabetes mellitus. Since insufficient or no insulin is produced the blood glucose levels will start rising. Attention for signs such as frequent urination, thirst and fatigue and weight loss should be given. Blood glucose monitoring should be performed frequently so that if needed the necessary treatment can be given and diabetes will be controlled.

According to Abraham (2002) 90% of patients with pancreatic cancer experience symptoms of obstructive jaundice. Jaundice occurs when bilirubin builds up in the blood stream. In normal people bilirubin is produced by the liver, stored in the gall bladder and bile duct and then secreted in the small intestine. In patients with pancreatic cancer, the tumor blocks the bile duct and bilirubin accumulates in the bloodstream. Jaundice manifests itself by yellowing of the skin, the conjunctival membranes over the sclerae, dark urination as well as pruritis. According to Abraham (2002) the relief of jaundice should be a major therapeutic goal since it has a direct effect over the quality life of the patient. Jaundice can be treated with a bile duct stent or surigical biliary bypass. The necessary assessment should be done so that jaundice can be treated as early as possible and some interventions such as good skin care, applying lotions to prevent dryness, avoiding hot waters and keeping room temperature cooler can help make the patient more comfortable (University of Michigan , 2007).