Lung Cancer Community Health Care Service - Essay Example

Lung Cancer – Community Health Care Service Introduction Symptoms of lung cancers in general are, (1) persistent cough, (2) blood in cough, (3) wheezing, (4) feeling breathlessness, (5) chest pains, and (6) a hoarse voice. In the case of Clare, the disease is in the advanced fourth stage. Fatigue and sleep disorders experienced by her are the side effects of the disease. There may also be problems such as nausea and vomiting caused by anti-cancer therapy. Roscoe et al (2007, p.36) observed that cancer related fatigue and cancer-related sleep disorders are increasingly reported as part of a cluster of three or more interrelated symptoms, including pain, depression, and loss of concentration and other cognitive functions, suggesting that CRF and cancer-related sleep disorders may share a common underlying etiology. At the stage four, the disease is not curable and the body is not in a condition to tolerate any further treatment and the accompanied pain. At some point of time the painful and the difficult decision to stop giving further treatment is considered. Mitigation of the hardships through palliative care rests in the hands of the nurses and care givers. When the patient is in terminal stage, the quality time spent by the near and dear ones with the patient and the spiritual support given to them are very important in the end of life care. The process needs little empathy on the part of the family and the society to overcome the barriers in giving the much needed support. Andrew’s efforts in this direction indicate his love and affection towards his wife, and his understanding is also borne out of practical considerations. Case study and the background Patient history: Clare is a 65 year old woman, with lung cancer, an eventually fatal condition. Clare suffers from breathlessness, cough and fatigue. She gets distressed by her inability to ‘catch her breath’. Sometimes she has trouble sleeping at night and is frequently sleepy during the day. She doesn’t have many strategies to help her manage her symptoms. The support in terms of physical, psychological, social, spiritual, and practical needs of patients and caregivers is essential for a peaceful end of life of the patient. Though there may be several approaches in dealing with a subject, as far as the end of life care is concerned, in the absence of complete cure beyond certain stage, the important issues are pain management, physical support in day to day activities, family support in overcoming the emotional distress and spiritual support aiming to prepare the patients to cope up with the anxiety and the emotional strain which is amply reflected in the statement of Clare “She views her illness as a challenge as it impacts on what she can do and she doesn’t feel in control of her life”. Clare also understands she doesn’t have many strategies to help her manage her symptoms. This means she has graciously accepted the consequences of her disease and bravely prepares herself to face the situation. We can also observe that when the family is taking all efforts to support the ailing patient, the community is moved by their sacrifice and the people would like to participate in the family’s efforts by offering solace to the patient by their visits and presence. Psychosocial care and pain management care are like two sides of a coin in respect of end of life care. Hope is the basis of life, and if the patient is convinced of no purpose being served in his/her existence, the usefulness of prolonging his life has no meaning. The anti-cancer treatment, and eventually the pain management in respect of lung cancer patients due to the fact that the disease is not curable beyond certain stage, is neither useful to the patient nor his family, unless the patients are provided with psychosocial care. The evolution of hospice care could be traced back to the lacunae in giving treatment to the end-of-life patients, as the pain is not restricted only to the physical aspects. The holistic assessment of the needs of patients/their families is done by the specialists qualified and trained in psychosocial interventions. Clare’s two grown children are married and live interstate.  It is said that she keeps in frequent phone contact. They may not be aware of the need for their presence and consolation to their mother that is more important than the financial support, which is evidently not a problem in this case. The nurses play an important role in providing palliative care as equipped with the requisite knowledge and experience, to help the patient and the family to cope up with the patient’s illness and the other attendant issues, though the specialist healthcare staffs provide psychosocial care broadly. The objective sought to be achieved in palliative care is ‘quality life’ for the patients as well as their families by treating the dying process as normal and undertaking effective pain management which is supplemented with psychological and spiritual care, leaving death to its normal course; neither prolonging nor hastening the process. Evidence based practice Evidence based practice involves assessing, appraising and applying the best evidence from the nursing and medical experience to improve the quality in home care nursing not only in the management of symptoms and palliative care but also the entire gamut of health care in respect of end of life care, as the evidence based practice takes into account even the contamination of nurse’s bags, in the backdrop of vulnerability of the patients to contagious diseases on account of their reduced immunity or defenses in avoiding infections. Melnyk and Fineout-Overholt (2005, p.3-4) stressed the need for evidence based practice and questions: “If you were diagnosed with cancer today and were faced with the decision about which type of chemotherapy to choose, would you want to know the evidence regarding the risks and benefits of each therapeutic agent as generated from prior clinical trials with other similar cancer patients?” The home care nursing involves decision making on several issues with regard to guidance to the patient and their family, medicines, dosage, diet, pain, and so on after taking into consideration the other factors such as cost involved, family support available and other constraints on day-to-day basis. The literature or research data available may not be completely relevant to the circumstances available, leaving an element of discretion on the part of the medical professionals. Pipe, et al states “Nurses face a real challenge when translating best evidence into clinical practice. For example, the relevant research-based databases are not comprehensive in many areas. Also, there is an ongoing explosion in the amount and type of information available”.  Community palliative care service Clare’s general practitioner has just referred her to the community palliative care service. Palliative care service is holistic and multidisciplinary. Under the ideal situation, care includes medical, nursing, other related health services and voluntary services. In community care support for the families and friends is given and it includes grief and bereavement support as well. The patients are normally given choices with regard to the type of care needed and the place it is required to be delivered. “Appropriate health care is based on evidence to ensure that the right thing is done to the right person at the right time, avoiding over and under utilisation and unnecessary variation in the practice and standard of care. This requires mechanisms that promote and embed evidence- based practice that involves, and is tailored to, individuals.” (Victorian Government Department of Human Services, 2007) Symptoms: Clare’s condition is fatal. She suffers from breathlessness, cough and fatigue. Sometimes she has trouble sleeping at night and is frequently sleepy during the day. Breathing difficulties (Dyspnea): There are various emergency symptoms related to cancer. But, breathing difficulties causes distress to the patient to the maximum extent. Since the direct causes underlying this symptom is very complex in nature, it poses problems to the caregivers as well. Rosenbaum (2006, p.63-64) states “The first goal is to try to reverse the cancer process, which may help alleviate some of the dyspnea problems.   Chemotherapy and radiotherapy used as treatments also may cause fatigue, weakness, and dyspnea.” Though the statement seems to be contradictory, it is understandable that there is a fine balancing act involved on the part of the palliative care providers. The judicious mix of treatment to the disease as far as practicable combined with the pain management is a challenge to the medical professionals, since the practical considerations and methodology based on evidence based practice vary from patient to patient. Cough: One of the common symptoms in the case of lung cancer is persistent cough. Blockage of airway can also cause shortness of breath results into coughing and chest pain. Some people cough up blood or sputum streaked with blood. Fairchild et al (2007) states “Palliative-intent radiotherapy (RT) is effective for improvement of symptoms resulting from intrathoracic disease, such as hemoptysis, cough, chest pain, dyspnea, and airway obstruction, and in approximately one third of patients, improves global QoL” Fatigue: Fatigue is one of the advanced cancer symptom observed in the patients, and is universal on referral. Hauser et al (2008, p.372) states “Potential contributory factors include anemia, anxiety, cachexia, depression, electrolyte disturbances, hypothyroidism, infections, insomnia, medications, nausea, pain, and antitumor treatment (chemotherapy, immunotherapy, radiation therapy, and surgery)” and their study reveals fatigue was universal, severe, and associated with impairment in daily activities and poor quality of life. There is no universal definition for cancer related fatigue (CRF) and it is not graded with reference to its severity. Fatigue is not normally reported by care givers and other professionals and not treated effectively as it is taken for granted in advanced cancer. There may be several factors such as poor communication, availability of medicines and other facilities provided. Fatigue leads to inability to function normally and accompanied with pain or dyspnea. Naturally it affects the mood and sleep of the patients and causes depression and anxiety. Hauser et al (2008, p.376) states that “Palliative radiotherapy (in contrast to curative) uses lower doses and potentially improves symptoms like pain, thus perhaps indirectly lessening fatigue and improving ability to perform activities.” Sometimes the treatment given for cancers can cause dysphagia. Gonzalez, F (2008, p.398) states “Dysphagia, though uncommon, can be quite debilitating and can mimic a paraneoplastic syndrome”. It is pertinent to note this point here as Paraneoplastic syndromes are present with the lung cancers among middle aged or older patients. Existential issues: The issues relates to the conditions of existence of the individuals, their emotional behavior, activities, responsibilities toward the family, relatives, friends and the community and thoughts. In palliative care, it is important to understand the views of the health care staff about the existential issues among patients in respect of cancer and their responsibility. The study of Browall et al (2009, p.59) categorizes the issues for greater perception: “The first category, “life and death,” was based on joy of living and thoughts of dying. The second category “meaning,” consisted of acceptance, reevaluation, hope, and faith. The third category, “freedom of choice,” consisted of responsibility and integrity, and the fourth and last category, “relationships and solitude,” consisted of alleviation, dependency, and loss).” These categories are subdivided further for better understanding and analysis. The important point is that the health care staff normally exhibit greater understanding and confidence in dealing with the issues raised by the patients. The ‘life and death’ is an important issue to the patients rather than being ideal by keeping in good spirit, positive attitude and normalcy in day to day life, because, it is but natural that a patient wants to experience and enjoy the life ‘as it is’ and be satisfied with the life when they are living. Small things in life like a peg of whisky to enjoy, listening to a tune they like and talking about his achievements in life to an earnest listener is more important to the patients with a good meaning. The death involves fear of ‘unknown’, question of ‘life after death’ and the ‘death pangs’ which may involve spasm, seizure or wrench. Role of Oncology Nurses: In providing palliative care to the patients, the evidence-based clinical practice guidelines issued by the Oncology Nursing Society, psychosocial care is covered elaborately: For example, Guideline A (16, p.9) states that the Nurse “Performs a comprehensive assessment of functional status and the impact on activities of daily living, including but not limited to the following domains; Psychological Role Social Cognitive Physical” and, Guideline A (20, p.9) states that the “Assesses the roles, tasks, and stressors of individuals, families, and caregivers and their ability to manage the illness experience (e.g., resources, support services, equipment, transportation, child care, anxiety, depression)” among the other responsibilities. The guidelines also emphasize the importance of interpersonal relationship with the patients and their families. In a Community Health Care Service set up the responsibilities of the nurses includes, but not limited to coordination of the end-of-life care in collaboration with patients, families, caregivers, and other members of the multidisciplinary healthcare team. Psychosocial care provided to the patient plays an important role in taking care of the psychological and emotional needs of the patients and chronic pain management is also interlinked to the resolution of the psychological issues involved in the end of life care,. Holistic care It is not restricted to treatment and pain management, especially in the case of end of life care. Lack of immunity on the part of the patients makes them vulnerable to so many infectious diseases. Therefore, protection of the patient from infections which may cause problems such as cold, fever, allergy and increased pain needs realistic assessment and proper as well as timely clinical investigations for taking remedial measures. Generalized approach with a preconceived notion that the terminal illness involves complications and pain should be discarded in favor of evidence based practice. The overall health condition of the cancer patient and the relationship of the other diseases with the cancer in the patients should be taken into consideration after clinical examination in respect of the other ailments while giving end of life care for effective results. For example, in the case of cancer patients with diabetics, the impact of diabetics on the cancer patients deserves special attention, because evidence from various studies indicates higher rate of mortality in the case cancer patients with diabetics. Richardson and Pollack state that “When treating cancer patients who have diabetes, clinicians must consider the cardiac, renal, and neurologic complications commonly associated with diabetes...the coexistence of diabetes and cancer will increase as the US population ages”.  Dosage of medicines varies with the stage of the disease, age, weight of the patient and overall health conditions of the patient. Access to pain relief is considered as a human rights issue to-day. The effective palliative care depends upon the availability of quality drugs. A report for World Hospice and Palliative Care Day 2007 published by ‘Help the Hospices for the Worldwide Palliative Care Alliance’ states “Many pharmaceutical companies are not interested in manufacturing morphine or in obtaining a licence for their formulation in countries where usage is thought to be low and bureaucracy potentially cumbersome,” and further states that “Over the last 10 years access to analgesics has increased substantially in a number of countries or regions within a country.” The side effects of the medicines and analgesics should be carefully monitored for considering substitutes or regulate the dosage in line with the need. Side effects of the medicines in palliative care for the end of life patients are not avoidable in most of the cases. When the curability by way of surgery as an option for palliation is not available, especially in the case of lung cancer patients, the importance of the role of pain management becomes obvious. However, it is important to strike a balance between the side effects caused by the treatment/pain management measures and the benefits of palliative care in terms of reduction in pain. Therefore, constant evaluation in this respect to improve the quality of the service is very essential. Opioid consumption in cancer patients is on the rise. Opioid therapy is needed for the tumour-induced and tumour-unrelated pain. Zylicz, Z. and Mercadante, S. (2010, p.31) state “There are data to suggest that widening the activity spectrum of opioids may be the way forward in order to decrease adverse effects and maintain analgesia”. On account of improved treatments and effective palliative care, the cancer patients now live longer and hence the expertise in opioid therapy on the part of the nursing and other professionals involved in palliative care is of paramount importance in evidence based practice. Qaseem, et al (2008) states “Strong evidence from trials of patients with cancer supports the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain”.  There are nutrition related side effects in the cancer patients. National care institute (2009) identifies “Cachexia,  Feeling too full to eat enough food, Bloating, Anorexia, Constipation, Dry mouth, Taste changes, Nausea, Vomiting and Inability to swallow” as nutrition related symptoms in advanced cancer, and therefore, the palliative care includes nutrition therapy. The decision with regard to nutrition support is taken considering the advantages, disadvantages, costs involved and the associated risks, under the guidance and advice of a registered dietitian obtained. Psychosocial care A study by Krajnik et al (2008, p.159) shows that “the families remembered feelings of loneliness and helplessness when confronted with the psychological suffering of their loved ones and the financial burdens caused… Professionals involved in palliative care should acknowledge that holistic care requires sensitivity, not only to the physical but also to the psychosocial and spiritual aspects of end-of-life care”. The fact that psychosocial care plays an important role in reducing the distress and improving the quality of life underlines the need for evidence based psychosocial care for advanced cancer and treatment of the patients consistent with the evidence. The difficulty in evaluation and measurement of the causes as well as the effects related to the psychological intervention is a major challenge with regard to the nature of the evidence in the absence of evidence based recommendations and established standards to the required level. Martensson et al (2007) states: Nurses caring for patients with cancer must be aware of the risk of overestimating emotional distress and underestimating coping resources and quality of life when they assess a patient’s situation. In the assessment phase, nurses should pay more attention to the patient’s internal resources. Increased awareness of a patient’s confidence in his/her coping ability may improve nurses’ ability to make correct assessments of the patient’s situation and their ability to plan for individualized care for that patient. The patients in the advanced stages of the disease many a times wish to hasten death due to physical or psychological suffering. It could be observed that many symptoms such as depression and sleeplessness though borne out of disease could be traced back to emotional and psychological feelings of the patient as well, whether the reasons are perceived or real. In any case, the active participation and association of the family members is essential in helping the patient to overcome the distress. The palliative care service focuses on quality of life with a ‘whole person’ approach with respect for the patients and their self-determination and choices as well as taking into account the palliative care needs of the family. Apart from the physical pain caused by the disease, the feeling by a patient of being ignored, within the family, friends and relatives circles and community could be a greater source of pain psychologically. Seeking advice and guidance from the patient in the normal course as it was done prior to illness could make him feel important in the scheme of things. Liaison with the oncology social worker will help in providing counseling and education to the patients and their families. Referrals to community resources group for lending support to the patients and their families by a social worker goes a long way in mitigating the hardships faced by the patient and the family, which may be otherwise very difficult to cope up with. This process improves the quality of life as the interactions dispel the fears and instill hope in the minds of the patients and their families. Identification and mobilization of the resources, which is the main cause for concern in respect of the patients from the economically weaker sections of the society, is made easier through the social workers. The social worker also provides bereavement support to the family, which may include religious service as well. It is pertinent to note here that the New York Palliative Care Information Act (2009) states: IF A PATIENT IS DIAGNOSED WITH A TERMINAL ILLNESS OR CONDITION, THE PATIENT'S ATTENDING HEALTH CARE PRACTITIONER SHALL OFFER TO PROVIDE THE PATIENT WITH INFORMATION AND COUNSELING REGARDING PALLIATIVE CARE AND END-OF-LIFE OPTIONS APPROPRIATE TO THE PATIENT, INCLUDING BUT NOT LIMITED TO: THE RANGE OF OPTIONS APPROPRIATE TO THE PATIENT; THE PROGNOSIS,RISKS AND BENEFITS OF THE VARIOUS OPTIONS; AND THE PATIENT'S LEGAL RIGHTS TO COMPREHENSIVE PAIN AND SYMPTOM MANAGEMENT AT THE END OF LIFE. Psychosocial care for Clare The patient is very much a part of the family and the community, and there is no neglect, isolation or indifference in attitude is felt by the patient. Intolerant attitude of the patients and their families toward each other, commonly noticed in the society, which needs education and counseling by the social care activists in palliative care, is clearly absent in the case of Clare. The patient’s husband Andrew is willing to do anything more he can do to help Clare. The patient is positive in her approach to the consequences of the disease and willing to face the difficulties associated with the disease with equanimity. She is surprised by the number of people who have ‘come out of the woodwork’ and have come to visit her at home. But, we can understand that she still needs assistance and support in her efforts to lead a normal life, when she states that personal relationships are more meaningful for her now and she misses seeing her children, even though she keeps in frequent phone contact. It is difficult to explain a mother’s love, affection and emotional attachment to her children and grand children. It is quite possible that Clare doesn’t want them to know her sufferings, because, it would make them visit her frequently at a considerable expense. Since Andrew wants to know whether he can do anything more to help Clare, it could be suggested that he keeps their married children fully informed of the developments, and requests them to make a visit. During their visit they could also be given counseling by the health care specialists, to enable them to understand their role in the end of life care, and its importance to the psychological well being of the patient. The community health care service to the patient in this case could be given in the home setting where the patient may feel more secured with greater sense of freedom and control. The patient’s privacy could be ensured by coordinating the visits of the specialist medical professionals, social workers and others to this effect by the oncology nurse, taking into account the daily routines and physical condition of the patient. The cost of hospice care could be prohibitive for the many households. Some insurers do not cover inpatient hospice care or other related services. Specialist social workers are in a position to come to the rescue of the patients and their families and provide information about the availability of resources and offer help in securing financial assistance through not-for-profit organizations or voluntary agencies and render legal advice in this respect. Conclusion The staff nurse plays an important role in implementing the research findings in clinical practice. Continuous learning and translation of information as learned into practice is aimed in quality delivery of service. In translating evidence into practice, the oncology nurse face many imponderables for the simple reason that many findings are not amenable to measurement, and comparison to some extent may be possible, but not computation in respect of the psychological issues. The role of nurses in the case of advanced lung cancer involves coordination at various levels, which needs considerable experience in dealing with the variety of situations and dedication on the part of the nursing community. The nursing professionals in their day to day activity in giving care to the cancer patients like Clare are required to take several decisions with discretion in the interest of the patient and their families. Evidence based practice ensures quality in giving treatment as well as excellence in profession. References Browall, M., Melin-Johansson, C., Strang, S., Danielson, E.and Henoch, I (2009), Health care staff ’s opinions about existential issues among patients with cancer, Palliative and Supportive Care (2010), 8, 59–68.Cambridge University Press, 2010 1478-9515/10 doi:10.1017/S147895150999071X Fairchild, A., Harris, K., Barness, E., Wong, R., Lutz, S., Bezjak, A., Cheung, P. and Chow. E. (2007) Palliative Thoracic Radiotherapy for Lung Cancer: A Systematic Review, Journal of Clinical Oncology, Vol 26, No 24 (August 20), 2008: pp. 4001-4011. American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.15.3312. Retrieved from http://jco.ascopubs.org/content/26/24/4001.full. Gonzalez, F (2008) Extrapyramidal Syndrome Presenting as Dysphagia: A Case Report, AM J HOSP PALLIAT CARE 2008 25: 398 DOI: 10.1177/1049909108322367, Sage Publications Hauser, K., Walsh, D., Rybicki, L. A., Davis, M. P. and Seyidova-Khoshknabi, D. (2008). Fatigue in Advanced Cancer: A Prospective Study, AM J HOSP PALLIAT CARE 2008 25: 372 DOI: 10.1177/1049909108319267, Sage Publications. Help the Hospices for the Worldwide Palliative Care Alliance (2007), Access to pain relief – An essential human right, http://docs.google.com/viewer?a=v&q=cache:N64vGuIHfacJ:www.worldday.org/EasySiteWeb/GatewayLink.aspx%3FalId%3D5603+A.access_to_pain_relief_a_human_right_world_day.pdf&hl=en&gl=in&pid=bl&srcid=ADGEESidThB9ZE5eZRrcAwPyiAgbaoQ0DCr5V4katXNSLXDdikkQlGnsiAN1SCf05BOExcVyqCONrzNYUyo2uN6sU5E2tnMltcHUu7TN3Op6WidGBa8PuE8p4MbLiqKnZuGNw8vFXqr8&sig=AHIEtbROG-0QmiRUqS-8ha4FD5uZMyaBGA Krajnik, M., Szymanowska, A., Adamczyk, A., Kozaka, J., Skrzypski, M. Szostakiewicz, B. and Jassem, E. (2008), The last months of lung cancer patients’ lives, in the memory of their relatives. A qualitative study based on in-depth interviews with family members, Adv. Pall. Med. 2008; 7: 159–170, Retrieved from http://www.advpm.eu/ Martensson, G., Carlsson, M. and Lampic, C. (2007, p.359), Do nurses and cancer patients agree on cancer patients’ coping resources, emotional distress and quality of life? European Journal of Cancer CareVolume 17, Issue 4, 350–360, July 2008 Blackwell Publishing Ltd., http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2354.2007.00866.x/full Melnyk, B. M. and Fineout-Overhold, E. (2005). Evidence-Based Practice in Nursing & Healthcare, Lippincott Williams and Wilkins National Cancer Institute (2009), Nutrition in Advanced Cancer, 29 Apr 2009, http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/Patient/page6 Oncology Nursing Society (2007), Oncology Nurse Practitioner Competencies, http://www.ons.org/Publications Pipe, T. B., Wellik, K. E., Buchda, V. L., Hansen, C. M. and Martyn, D. R. (2005), Implementing Evidence-Based Nursing Practice, Medscape Today, Retrieved from http://www.medscape.com/viewarticle/514532;meddomainjsession=qcsLMbhpMLNJBgThytG3cGh1NPfv0RTVvh92y2T0bxps0Tft2BqT!240056632 Society of Urologic Nurses and Associates, 31 Oct 2005. Qaseem, A., Snow, V., Shekelle, P., Casey Jr. D. E., Cross Jr. J. T., and Owens, D. K. (2008), Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians, Annals of Internal Medicine, American College of Physicians, 15 Jan 2008. http://www.annals.org/content/148/2/141.full Richardson, L. C. and Pollack, L. A. (2005), Therapy Insight: Influence of Type II Diabetes on the Development, Treatment and Outcomes of Cancer, Netscape Today, 14 Feb 2005, Nat Clin Pract Oncol. 2005;2(1):48-53. © 2005 Nature Publishing Group, Retrieved from http://www.medscape.com/viewarticle/498299 Roscoe, J. A., Kaufman, M. E., Matteson-Rusby, S. E., Palesh, O. G., Ryan. J. L., Kohli, S., Perlis, M. L. and Morrow, G. R. (2007) Cancer-Related Fatigue and Sleep Disorders, The Oncologist, 2007;12;35-42. Rosenbaum, E. H. (2006), Dyspnea Supportive Care for Cancer, Abstracted article - Dyspnea in Cancer Patients Needs More Attention, Journal of Supportive Oncology, vol. 4, 2, February 2006., E. H. retrieved from http://www.cancersupportivecare.com/dyspnea.html State of the New York (2009), New York Palliative Care Information Act, 17 Apr 2009, http://assembly.state.ny.us/leg/?default_fld=&bn=+A07617%09%09&Summary=Y&Actions=Y&Text=Y Victorian Government Department of Human Services, (2007) Clinical excellence in cancer care, Melbourne, Victoria, Australia. www.health.vic.gov.au/cancer Zylicz, Z. and Mercadante, S. (2010) Is there enough evidence to advocate opioid combinations? Does one and one make two or more? Adv. Pall. Med. 2010; 9, 2: 31–38, Retrieve from http://www.advpm.eu/ Read More