Palliative Pain Management in Advanced Breast Cancer - Case Study Example

 Palliative Pain Management in Advanced Breast Cancer Advanced malignancy care is a challenge to medical professionals like nurses for many reasons. Besides instituting various treatments that prevent progression of the disease, reduce development of complications and prolong life of the patient, nurses are also posed with a challenge of relieving devastating symptoms of the disease like pain which add to the miserable state of the patient. For those in terminal stages of cancer, provision of palliative care remains the only hope to relieve the patient from suffering to some extent (WHO, 2009). The corner stone of palliative care is pain management (WHO, 2009). This is because pain is very severe and distressing in cancer patients and can lead to physical disability, emotional maladjustment, social detachment, psychological depression and distress, sleep disturbances, loss of appetite, and feeling of unwell and above all make their journey to death miserable (National Health Service, 2006). In fact, pain is the only aspect of terminal illness that can be relieved. Nurses taking care of terminally ill cancer patients must be aware of this and take necessary measures to relieve pain in them (Kearney, Richardson, & Giulio, 2000). This essay discusses pain relief management in a terminally ill breast cancer patient as an exercise to gain further understanding into palliative care of advanced malignancy. 1. Client Personal details Name: Maha Munif Sex: Female Nationality: Suadi Date of birth: 23 October 1955 Age: 54 years old Weight: 80 kilograms Height: 178 cm Religion: Muslim Marital status: Married with three daughters Level of education: High school completed in 1968 Past medical history: Type II Diabetes Mellitus, hypertension and Breast Cancer first diagnosed in October, 2008 Significant family history: Diabetes mellitus, hypertension and breast cancer Smoking habits: none Alcohol habits: none Allergies: Unknown Family role Mrs. Maha is a mother of 3 girls. Her first daughter is married and has come for delivery of her second child. Mrs. Maha is an excellent home maker, a great support to her husband even during the days he had unemployment, a role model to her daughters, a good caretaker to her grand child and her pregnant daughter. As an obedient and caring daughter-in-law, a supportive wife, an able and intelligent mother, and a loving grandmother, she is an indispensable member of the family. Following diagnosis of breast cancer which progressed rapidly, the woman became less active with her family because of frequent admissions to the hospital, surgery, chemotherapy and complications of the disease and treatments. Culture Mrs. Maha is a born Muslim, raised with strict principles and norms of Islam. She was always a staunch believer of Allah and acknowledged that everything that happened in her life was in accordance of the will of Allah. Even during the terminal ill stages, she continued to pray 5 times a day without fail. She fasted during Ramzan, even the previous year. She remembered Allah in every sentence she delivered saying "it is the will of Allah." She reads Holy Quran every day and in the terminal ill stage, her daughters read it aloud for her. She seeks solace in doing so. Financial status Mrs. Maha is a home maker. Her husband is an accountant in one of the government offices. In Saudi Arabia, the government takes care of all the health expenses of the citizens and hence there is no economic crunch to gain medical expertise and treatment. Social activities Previously, Mrs. Maha used to take part in many social activities. However, the state of disease has made her lose interest in social life and she has become less connected with friends and extended family members. She prefers loneliness now and hears to Holy Quran most of the times. Biological profile Current diagnosis The current diagnosis in Maha is advanced infiltrative ductal carcinoma of the left breast with metastasis in the liver and bone. Pathophysiology Carcinoma arising from the tissue of the breast is known as breast cancer. Breast cancer is the second leading cause of death due to cancer in women, only second to lung cancer (Wright and Moroz, 2009). In Saudi, breast cancer is the most common malignancy in females (Rennert, 2009). The risk factors for development of breast cancer is female gender, advanced age, positive family history, late age of first parturition (beyond 30 years), hormone replacement therapy, atypical hyperplasia lesions in the breast, early menarche and late menopause, lifestyle factors and genetic predisposition (Wright and Moroz, 2009). 80 percent of the breast cancers arise from the ducts and is known as ductal breast cancer. Cancer that develops from the lobules is known as lobular cancer which accounts for 10 percent of breast cancer cases. (Buechler and Buechler, 2007). The most common histologic type is the epithelial tumor (Wright and Moros, 2009). Epithelial tumors include adenomas, intraductal papilloma, intraductal and lobular carcinoma in situ, invasive carcinoma, both ductal and invasive, and Paget's disease of the nipple (Wright and Moros, 2009). Other histological types are adenocarcinoma, primary lymphoma and angiosarcoma (Buechler and Buechler, 2007). The key determinant of prognosis of breast malignancy is the invasiveness (Wright and Moros, 2009). Lesions which are non-invasive are limited by the basement membrane. There are 5 pathologic subtypes of ductal carcinoma which are papillary, comedo, micropappilary, cribriform and solid. Most of the times, the lesions are a combination of the two (Wright and Moros, 2009). Presence of comedonecrosis is a risk factor for development of ipsilateral breast cancer. The most commonly diagnosed carcinoma of the breast is the infiltrating ductal carcinoma which accounts for more than 75 percent of breast cancers (Buechler and Buechler, 2007). It has a good potential to metastatise to other parts of the body through blood and lymphatics and also to the opposite breast. Level of the disease Breast cancer is staged from 0-5 (Buechler and Buechler, 2007). Stage 0 is the noninvasive breast cancer in which the carcinoma is in situ and no lymph nodes are affected or metastases are seen. Stage I is when the size of the tumor is less than 2 cm and has not spread from the breast. In Stage II, the cancer has spread to the ipsilateral axillary lymph nodes. Stage III is when the tumor is more than 5 cm and has involved greater lymph nodes. Stage IV is metastatic breast cancer. The key determinant for prognosis and treatment of breast cancer is the invasiveness (Buechler and Buechler, 2007). At the time of diagnosis in The patient, the level of breast cancer was Stage II. The current level of the disease is Stage IV. Mrs. Maha has advanced metastatic breast cancer with metastasis in the liver and bone Spiritual profile 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. When Mrs. Maha came to know of her diagnosis about a year ago, she did not believe it. She thought that there was some mistake in the report. She had to be counseled and educated about the disease and the importance of undergoing treatment. Then over a period of few weeks, she adjusted emotionally to the disease she had. Frequent hospital admissions, surgery, chemotherapy, side effects to treatment made her realize and acknowledge her disease state. She then adopted the spiritual way to console herself. Mrs. Maha believes in Allah and she keeps thinking about him and this makes her gain complete spirituality. She listens to Quran and continues prayers 5 times a day. 2. Symptoms Symptom manifestation 55 year old Maha met her gynecologist in October 2008 for complaints of "able to feel" a mass in her left breast which she noticed about a week prior to consultation. She had no other symptoms until then. She was on regular check up for her hypertension and diabetes which were remarkably under control. Examination of the breasts revealed the size of mass to be 3cm X 4 cm with mild puckering and changes in texture of the skin over the mass. A few axillary lymph nodes in the left axillary region were palpable. After examination and evaluation, the woman was advised to get a mammogram done which confirmed invasive ductal carcinoma. Based on this report, further evaluation of the mass was done using ultrasound of the breast and surgical biopsy of the mass. Histopathological examination revealed that the mass was epithelial invasive ductal carcinoma. Testing for hormone receptors revealed that the tumor had hormone receptors and the cancer was suitable for hormonal therapy (Buechler and Buechler, 2008). Further tests were aimed to look into metastasis. The final diagnosis that was established in the patient was Stage-2 breast cancer. Though Mrs. Maha was very upset over the diagnosis, she went ahead with the treatment in consultation with her husband. She underwent left sided mastectomy with removal of left axillary lymph nodes. She was then started on tamoxifen therapy. Despite aggressive anti-cancer management, the woman developed metastases over few months and became terminally ill within a year. She developed metastases in the liver and bone subsequent to which she became very ill, pale and sick looking. Having enjoyed a contentful life with full of love, happiness and luxury, Mrs. Maha pleaded the treating oncologist to provide care which allowed her to live in peace for the few remaining days in her life. The team of doctors, after consultation with the her husband and other family members initiated palliative care. The main issue that was dealt with in this stage was pain relief. Current symptoms in the patient Mrs. Maha is in terminally ill stage. Though she is conscious, alert and oriented, she appears depressed and in low mood. She refuses to talk much and divulge any information pertaining to her symptoms. The most common symptom in her now is pain. Mrs. Maha has generalized body ache and on and off fever for the past few months. However, what is bothering her the most is pain in the lower back due to vertebral metastasis and burning sensation over her left upper limb. The patient also has loss of appetite and weight loss. Other symptoms which wax and wane in the patient are nausea and vomiting, abdominal pain, constipation, sleep disturbances, fatigue, delirium and mouth sores. Causes of symptoms Pain in Mrs. Maha is mainly related to cancer and its treatment. The metastases of breast cancer can compress and cause pressure resulting in pain. Metastasis to bone causes bone pain. Bone pain is also related to chemotherapy and osteoporosis (Mishra et al, 2004). The burning neuropathic pain of her left upper limb is due to herpetic neuralgia (Robb, Bennett and Johnson, 2008). Other symptoms are mainly related to the cancer catabolic state and side effects of treatment (Bueschler and Bueshler, 2007). Management of symptoms Initially pain in Mrs. Maha was managed with ibuprofen as per the WHO guidelines (2009) for pain relief in cancer patients. However, as the pain increased and became unresponsive to the drug, the analgesic was stepped up to codeine and then to hydrocomorphone and fentanyl (WHO, 2009). Onset of severe back ache which was suggestive of vertebral metastases was managed with oral biphosphonate clodronate (Singhal and Gohel, 2008). Fever was controlled with oral paracetamol. Whenever she had vomiting, she was given paracetamol through per-rectal route. Nausea and vomiting were managed with ondansetron, a centrally acting antiemetic drug (Buechler and Buechler, 2007). Abdominal pain was managed with H1-antagonist pantodac. To relieve constipation, dulcolax was tried orally and per rectally. Although some improvement was noticed initially, unresponsiveness in the past few days prompted the physicians to administer enema atleast one in two days. Insomnia was managed with 0.25mg of alprazolam at bed time. Along with these medicines, Mrs. Maha was also give her diabetes and hypertension medicines and medicines for general health like calcium supplements and multivitamins. Critical discussion of pain and pain management Type of symptom Pain has been chosen to be discussed under this section. Pain is one of the major issues in terminally ill breast cancer patients.75- 80 percent of pain in cancer is mainly due to tumour pressure, 15- 19 percent is due to anticancer treatment and the remaining is due to causes unrelated to these two (Mishra et al, 2004). In patients with advanced breast cancer, like Mrs. Maha Munif, metastasis to bone can result in severe bone pain (Mishra et al, 2004). Neuropathic pain is another cause of pain in Mrs. Maha. Impact of pain on the patient Pain in Mrs. Maha affected the physical, social, psychological, emotional and spiritual well-being of the person (National Health Service, 2006). It contributed to loss of appetite, sleep disturbances, psychological distress, depression and a sense of loneliness. Due to pain, she was subjected to many medications in the form of oral and intravenous and also to procedures like trans electrical nerve stimulation. Pain also affected her family members who were affected emotionally to see their dear one in pain. Potential complications of pain The potential complications of pain are deterioration in the quality of life and side effects to various medications administered for pain relief like confusion, hallucinations and myoclonus (National Cancer Organisation, 2009). Pharmacological management of pain The management of pain was guided by the WHO (2009) analgesic ladder and opioid switch principle (National Cancer Organisationn, 2009). The drugs given were paracetamol, codeine, hydrocomethadone, fentanyl and clonodrate. Non-pharmacological management of pain The patient was give TENS for her left upper limb, hot packs over her back, and massage therapy over lower back. 3. Palliative treatment objectives Palliative care aims at relief of suffering, promotion of patient function, delivery of help to meet daily living needs, psychosocial support to the patient and the family and clarification of goals of care and associated treatments. According to the World Health Organisation (2009), 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." Palliative care integrates various aspects of patient care like the psychological and spiritual. It supports the patients to live as actively as possible as along as they are alive, it helps the family to cope with the illness of their dear one and also be composed with their bereavement. Palliative care is a team approach and through this approach it addresses the needs of patients and their families. The team also consists of a psychologist who counsels bereavement. 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). Pain management in palliative care Several practice guidelines have been developed to treat pain in cancer, the cornerstone of of which is analgesic therapy. The goals in pain management in Mrs. Maha would be to "achieve optimal pain relief with minimum or tolerable side effects within an acceptable time frame" (Mishra et al, 2004). It is important to manage pain because, pain can affect affect various other aspects of an individual life biophysical, psychosocial, spiritual and economic aspects (NHS, 2006). Pain in Mrs. Maha has lead to other symptoms like sleep disturbances, fatigue and depression. Her family members are distressed to see her suffer. Pharmacological pain management The most popular guidelines for pain management in cancer patients is by WHO (2009). The WHO (2009) established a 3-step analgesic ladder for management of pain in cancer patients. Research has shown that this mode of treatment provides adequate analgesia to more than 75 percent terminally ill patients (Mishra et al, 2004). Stepping up the ladder is guided by pain score. Mild pain with scores between 1-4 must be treated with nonsteroidal antiinflammatory agents or NSAID. Pain scores of 5-6 suggestive of moderate pain must be treated with weak opioids. Severe pain scores between 7-10 must be managed with strong opioids like hydromorphone, morphine and fentanyl (WHO, 2009). Type of drugs During the initial stages of pain, Mrs. Maha received ibuprofen which is a NSAID at the dose of 400 mg every 8 hours. However, after few days, pain worsened and Mrs. Maha Munif was started on codeine which is a mild opioid analgesic. As days went by, her pain worsened and she was started on hydromorphone. As the cancer advanced, metastases to the vertebrae caused severe back ache to the patient who neither could sleep nor could stay awake. Oral biphosphonate clodronate was started in the patient in conjunction with opioid therapy. Though research has shown the benefits of intravenous pamidronate and zoledronic acid in the management of osseous metastases, oral biphosphonates have been studied widely and clinically proven in breast cancer metastases (Poznak, 2002). Other biphosphonates which have been studied are oral ibandronate and pamidronate. Action and contraindications Pain management in Mrs. Maha was guided by cancer pain management protocols in strict adherence to constant assessment of pain, evaluation of response to pain, search for potential complications of pain medicines and upgrading of the drugs as and when needed. The pain control options were administered based on the needs of the patient and interventions were delivered in a logical, timely and coordinated fashion (National Cancer Organisation, 2009).Opioids were chosen mainly for the management of pain in Mrs. Maha because she was not responding to Ibuprofen and she developed abdominal pain. Side effects to NSAID administration are hepatic dysfunction, renal failure, gastric ulceration and myocardial infarction (National Cancer Organisation, 2009). Common side effects for to opioids are constipation, nausea, somnolence. Other side effects which are dose-limiting are confusion, hyperalgesia, hallucinations, sedation and myoclonus. There are reports that switching to alternative opioid can reduce these symptoms (National Cancer Organisation, 2009). Non-pharmacological interventions for pain Other than pharmacological approach to cancer pain management, non-pharmacological methods are also available which have been proved to be quite effective in bring down pain in a patient with advanced malignancy like Mrs. Maha. Research has shown that these approaches are not only effective, but also acceptable by patients. There are many non-pharmacological approaches to pain management, the most widely studied of which is transcutaneous electrical nerve stimulation or TENS. According to cochrane database, there is no effective evidence to recommend TENS as an useful modality of pain relief in cancer patients and that more research is warranted in this perspective TENS TENS is a non invasive safe method of applying electrical current through the skin for the purpose of gaining neuropathic pain control in cancer patients. The battery-operated TENS unit is connected to the surface of the skin using 2-3 electrodes. TENS can be modulated and mechanized to deliver either high intensity or low intensity electrical waves. While high intensity TENS activates delta-opioid receptors in the spinal cord and in the supraspinal region, low intensity TENS activates the mu-opioid receptors (Menefee and Monti, 2005). For Mrs. Maha, TENS was applied to the left upper limb to treat neuropathic pain of herpetic angina. Other non-pharmacological treatments Other common physical treatments used to relieve cancer pain is application of heat or cold or a combination of both and therapeutic exercise and massage (Menefee and Monti, 2005). The nursing staff provided with heat therapy for the back 3 times a day. A physiotherapist was employed to deliver massaging of the back. Psychological interventions for pain Along with physical modalities, Mrs Maha was also provided with psychological interventions. A study by Zaza and Baine (2002) revealed that pain in cancer can get worsened when associated with many other factors like depression, mood disturbances, psychological distress, anxiety and fear. The fear encountered is mainly fear of disease progression and painful death. Involvement of a psychiatrist or a psychologist in early stages of cancer can reduce the amount of pain, thus assisting in pharmacological management. various psychological interventions which have been useful for this purpose are cognitive-behavioural interventions and behavioural interventions. Since cancer affects the social well-being of the patient, various psycho-social interventions must be provided to allay pain. The three main interventions which have been designed for the purpose are provision of cancer education, hypnosis and other imagery-based treatment interventions and training in coping skills. According to Keefe, Abernethy and Campbell (2005), the focus of educational interventions is to help the patients understand assessment of pain so that barriers to the treatment of pain are overcome. Caregivers, family and friends also will need this education. According to Keefe et al (2005), providing education and training to the caregivers, increases the psychological and social functioning of the patient. 4. Holistic nursing care Nursing involvement with the palliative care client and family Setting of care Mrs. Maha Munif was provided palliative care at the Riyadh Kharj Hospital in Saudi. The hospital is one of the biggest health care agencies in the city of Riyadh with a bed capacity of 5000. The hospital is maintained by the Ministry of Defense and Aviation (Ministry of Defense and Aviation, 2008) and houses oncology centers separately for adults and children, both of which are well equipped with various diagnostic and therapeutic itinerary related to cancer diagnosis and management including stem cell transplant unit. The hospital has 20 beds to provide palliative care for terminally ill patients (Riyadh Kharj Hospital, 2008). Role of the family and friends and other team members The primary care givers in case of Mrs. Maha Munif were nursing staff in conjunction with her daughters and husband who coordinated with other members of the palliative care team The activities of the team are coordinated by the primary care physician. Other team members include nurses, 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). Palliative 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). Role of nursing staff Providing palliative care for terminally ill patients is posed with many challenges for the nurses, some of which are establishing a relationship of trust and being a part of the family. 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. In case of Mrs. Maha Munif, nurses need to really get involved to connect themselves with her because she already developed a shell of loneliness around her. On some occasions, she expressed distress in the form of anger, retaliation and helplessness. She refused to talk about her problems and difficulties. To surpass the shell, the nurses need to take initiative to respond to her needs immediately. 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. Other than dealing with the emotional aspects of the patient, palliative nurses have a role to balance various available treatments, provide education and counseling to the relatives of the patient and administer nursing processes at every step of care. They should communicate effectively with the patient and their family members and collaborate with other health professionals (Kearney, Richardson, & Giulio, 2000). Self palliative care Mrs. Maha Munif was not capable of self palliative care. This is because she refused to talk, opine and respond in many situations. She appeared depressed and would spend lot of time alone, praying to god. Coping strategies to pain and symptom control Mrs. Maha adopted spiritual way to cope with her illness and condition. This was possible because of the strong ties she had with Allah. There are many coping strategies to cope with terminal illness. While spirituality is one, other methods include voicing preferences and making the most of each day (Terminal Illness, 2009). Coping strategies for family and friends The family and friends got involved in the palliative care of the lady. They determined that providing care in such a situation not only wound bring peace to their loved one but also would give them some satisfaction. The husband and daughter also organised some religious alms and prayers to cope with the phase. Stage of acceptance Mrs. Maha had accepted her terminal illness and the persistence of symptoms. She now craved to be as close to her family and Allah. She was determined that believing in God would make her journey to death more peaceful and less painful. Conclusion Pain management is the cornerstone of cancer palliative care and can be enhanced by selecting drugs in consideration with their effectiveness and side effects. Comprehensive palliative care can be delivered by addressing not only the physical aspects of pain and other symptoms but also by addressing other needs of the patient like the psychological, spiritual, functional and emotional aspects. 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