Palliative Care for Lung Cancer Patient - Essay Example

PALLIATIVE CARE FOR LUNG CANSER PATIENT Introduction Though there have been remarkable technological developments in diagnostics, prevention and treatments during the last decade, according to the National Foundation for Cancer Research (2010), “It is estimated that lung cancer accounts for about 15% of all new cancer cases in 2010, but will cause nearly 30% of all cancer deaths.” Bronchogenic carcinoma remains a challenge to the medical research and, due to the nature of the disease, the survival rate among the patients has not been improved effectively even under reasonably good standards of treatment. “Bronchogenic carcinoma is a major cause of mortality world-wide and the survival rate has not improved significantly in the last 20 years. Over 150000 new cases of lung cancer are diagnosed in Europe every year but less than 10 percent are cured…” (Doyle, Hanks , Cherny, and Calman, K., 2005) The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. (Morrow, 2009). It is an experience and assessment is difficult. There is no simple definition for palliative care also, and the definition based on the World Health Organization states “A Palliative care is care that improves the quality of life of patients and their families facing life-threatening illness. With palliative care particular attention is given to the prevention, assessment, and treatment of pain and other symptoms, and to the provision of psychological, spiritual and emotional support.” (Avert, 2010) Due to lack of effective surgical and medical cure especially for the lung tumors, the importance of palliative cure in this area has significantly increased. In the disease management of lung cancer major surgery is rarely justified for palliation. “The National Council for Hospice and Specialist Palliative Care Services (1997) has defined psychosocial care as concerned with the psychological and emotional well being of the patient and their family/carers, including issues of self-esteem, insight into an adaptation to the illness and its consequences, communication, social functioning and relationships.” (Jeffrey, 2003, p.1) Factors to be considered in palliative care Palliative care for the patients who are at the verge of death has several dimensions to it apart from the pain associated with the disease. Understanding these following factors is very important as the entire gamut of the care hinges on appreciating the complexities of these factors, as the issue is not restricted only to the medical treatment for the patients. Fear of Death pangs The fear of death has a psychological plane to it, and the disease also creates fear of death pangs. Stage 4 victims face dyspnea and difficulty in breathing which causes panic. Spiritual and religious may be necessary to strengthen the mental make of the patient. Emotional distress Cancer is a shock to the patients and their family which results into depression, anxiety and anger. Palliative care therefore involves physical as well as emotional approach. The family members, relatives and the friends’ presence and interaction should reassure the patient. Life cycle changes Lung cancer affects vocal cord which leads to hoarseness and changes in voice. Eating becomes difficult. Eventually the life cycle is altered and the patients find it difficult to cope up with this situation. The patient is required his habits, food and daily routine to adjust to the circumstances due to health conditions, and the transition phase would be gruesome. The patient needs support and consolation from the family members and care givers. Support and comfort to the patient Counseling for both patient and family should be effective. The emotional support provided should help the patient and the family through the grieving process. It is not uncommon to see that the family members wish for early demise of the patients as the distress saps the energy of the family members. Intolerant attitude towards care services The patients and the family members become intolerant towards the services mainly due to frustration. Understanding and patience on the part of the health care professionals is necessary. Pain causes impatience and resentment and turns into anger against the people around him or leads to frustration. Till the patient learns to live with the hospital setup, he needs assurance about pain relief and normalcy in his life to cope up with the situation. Physical strain The body becomes weaker day by day, and the pain increases. Breathing becomes difficult and the movements become clumsy and painful. The sexual needs of the patients are not satisfied. Pain relief becomes the primary objective especially in the case of stage 4 cancer patients, rather than the side effects. Family tensions When the patient is the sole bread winner for the family, or there are family arrangements or decisions to be made which needs the intervention of the patient, the situation creates tension within the family. Financial problems and hospice care The patients choose hospice for end-of-life care. But, the cost involved in hospice care is high, and the inpatient and outpatient fees reimbursed through insurance is fixed. Consequently providing palliative treatment to the patients has become difficult. According to Wright and Katz (2010), “Currently, oncologists focus on how well a tumor responds to chemotherapy, but they will soon have to examine improvement of symptoms and quality of life to justify treatment costs.” Enablers and Barriers to pain assessment management Enablers Improvements in communication and sharing of information should form the basis for the development of the long term strategy. Collection of data and analysis will enable formulation of a progressive policy. In this connection, support for the participation of the patients is of paramount importance and it should make them feel comfortable in contributing to the service planning and delivery. The perceptions and experiences of the patients about the care delivery will lead to modification of the existing strategies continuously with a view to make improvements from the stand point of the affected people based on the developments and knowledge gained. According to Miller (2009, p.23), in the case of cancer care there is “a need to look more deeply at constraints and enablers on the general practice side of the equation”. Standards Pain measurement is with reference to experience of pain. But assessment connotes wider scope in relation to intensity of the pain, duration, location and other contextual and situational factors. The CCHSA included pain assessment and management in its 2005 Standards. “Specific actions are suggested to meet the standard as it relates to assessment, management, monitoring, documentation and organizational responsibility. The criterion is evidence-based and includes the organization’s accountability to train and update health care professionals, patients and families on pain management options and strategies.” (Nova Scotia Chronic Pain Working Group, 2006). . Chronic pain management in Education Pain management requires training on the part of the medical professionals belong to various faculties such as medicine, pharmacy, radiotherapy, surgery and nursing. “Pain education for health professionals at all levels has been repeatedly identified as an important step to changing ineffective pain management practices.” (Nova Scotia Chronic Pain Working Group, 2006). When further progress in cure in the case of diseases like lung cancer is difficult to achieve, it is imperative that palliative care is given more attention and accorded top priority in education. Personnel policy The remuneration in this field should be commensurate with the hardships endured by the professionals in the performance of their duties. Devotion and sincerity required on the part of the professionals in dealing with the patients is phenomenal. The nursing home field is plagued with labor shortages, along with difficulties in worker retention, supervision and training opportunities. Common causes of high staff turnover include the difficulty of the work, relatively meager pay and benefits, a lack of respect for staff roles, frustration with the quality of care, and demanding paperwork and regulatory requirements. The professional stress in this area for the professionals is very high. (Center to Advanced Palliative Care, p.3.7) Therefore, suitable policy with regard to employment and remuneration will go a long way to improve the conditions. Skill, knowledge and training in assessment and pain management, especially in palliative care in respect of lung cancer patients is essential at all levels, due to lack of chances of cure at the advanced stages of the disease. Psychosocial care A comprehensive pain assessment and pain management involves psychosocial care to the patients to prepare them to cope up with the anxiety and the emotional strain caused by the pain. Intolerable pain associated with the disease, and the post surgery symptoms such as cough, dyspnea and chest pain and complications such as obstruction of trachea creates mental distress. “Obstruction of the trachea and main bronchi, with severe dyspnoea and stridor, is an infrequent but serious complication of lung cancer, leading to life threatening respiratory distress.” (Doyle, Hanks, Cherny, and Calman, K 2005, p.261) Therefore, palliative therapy should be supplemented with psychosocial care as it is very important to support the patient to make him feel like a whole person with spiritual and psychological care. Lethborg, and Brown (2009) discussed about a targeted orientation and distress screening (ODS) model used for newly diagnosed cancer patients at St. Vincent’s Hospital. The model identifies the unmet needs of the patients for the purpose of Orientation to the hospital. Then they perform psychosocial screening for distress and identify problems. A psychosocial profile of each patient is collated and disseminated. Barriers There are number of factors relating to patients, formal healthcare providers, caregivers, and family members involved in pain assessment and management of pain in a client with an eventually fatal condition of lung cancer. Nursing Nursing plays an important role as the nurses spend more time in the day-to-day activities with the patients, closely coordinating with the various needs of the patients and pay attention to the psychological needs while providing care to the dying patients. Center to Advanced Palliative Care (2008, P.3.7) states that “Inadequate staffing levels, the absence of continuous education, and inconsistency are widely acknowledged problems in nursing homes.” The End of life care has not been covered adequately in the nursing curriculum. Generally, the educational background with regard to EOL care is inconsistent and sometimes neglected altogether. European Men’s Health Forum (p.11) observes that “In lung cancer the longest delays are generally when patients do not seek medical attention. There are several reasons why. In lung cancer there is a long time period where there are no or few symptoms.” According to Brookshaw et al. (2009) poor understanding of prognosis, family anger and disagreements about treatment and poor communication between doctors and nurses about prognosis and care are the important barriers to the provision of palliative care services from the point of view of nurses and quoted ( Gott, Ahmedzai & Wood, 2001) ”Doctors and nurses disagree markedly on the palliative care needs of patients”. But, disagreements are sorted out over discussions amicably as it revolves around the welfare of the patients in a hospital situation. Referral & access barriers The following are considered to be the referral and access barriers to specialist palliative care services. There is reluctance on the part of the patients and their family members to be referred for palliative care due to patients’ perception that palliative care means imminent death. There is lack of understanding about whom to refer and when. Also, there is resistance among the professionals to “share” patients. Cultural background plays a significant role and the patients prefer residential care based on religious or cultural tenets. For example, in the case of women, there may be restrictions in respect of their stay in the hospital as per their customs in general. However, these restrictions could be overcome through the active participation of the female nursing professionals. Physician related and other barriers According to Nova Scotia Chronic Pain Working Group, the barriers in the assessment of pain include inadequate data relating to pain. The nature of pain which is multidimensional, timing of the assessment, interpretation of the data, proper utilization of the assessment measures, inadequacy in respect of documentation are also the important factors to be considered. Scotia Chronic Pain Working Group (2006, p.29) states, “One way to overcome these barriers in assessment is to build an “institutional commitment” to pain. “Institutionalizing” pain management practices can be achieved by incorporating basic principles of pain assessment and treatment into patterns of practice including documentation systems, policies and procedures, standards of practice, and orientation, continuing education and quality improvement programs.” In respect of hospice care, the primary barrier is the attitude on the part of the patient who refuses to accept the fact that they are facing death and the lack of understanding, misperceptions or misunderstanding on the part of the patient and their family members about the hospice care. There are also other issues involved such as cultural and religious beliefs of the patients and their families and the social stigma attached to the diseases. According to Corboy, McLaren, and McDonald (2009, p.3) there are barriers to patients’ participation in psychological support services in rural areas, viz. Logistical barriers such as awareness and access and Attitudinal barriers such as attitude to help seeking among cancer patients, reluctance in expressing need for help, imposition on medical personnel, stigma and query benefits. Science codex (2010) states quoting New England Journal of Medicine: “Integrating palliative care early in the treatment of patients with advanced lung cancer not only improved their mood and quality of life, it also extended their lives.” Palliative care for children Lung cancer can attack anyone irrespective of any age. Since the lungs of the children are not developed, it is difficult for them to cope up with the disease and it may result in fatigue, wheezing and other symptoms such as cough, weight loss, bronchitis and pneumonia. World health organization states that “Palliative care for children is the active total care of the childs body, mind and spirit, and also involves giving support to the family.”  The approach in the case of children should include their families, since the children need psychological support to cope up with the social distress. Brown and Anda (2010) observed "Adverse childhood experiences were associated with an increased risk of lung cancer, particularly premature death from lung cancer…” Legal and ethical issues Quill and Meier (2006) argued against the risk of empowering agents of the Drug Enforcement Agency (DEA) — whose traditional role is to prevent drug abuse and diversion — to evaluate the end-of-life practices of physicians whose patients die while receiving prescribed opioids or barbiturates and stated “A finding in favor of the Justice Department would not only nullify the Death with Dignity Act, permitting the DEA to penalize physicians for providing medications to hasten the deaths of terminally ill patients, but also have a chilling effect on physicians willingness to treat patients terminal symptoms.” Mitigation of pain and associated problems such as agitation and shortness of breath is of paramount importance in the case of terminal cases, because withstanding such pain is not going to serve any greater purpose in the life of the patient. When there is greater need for medication, the doctors should not be discouraged to act on their own discretion and forced to let down the patients. According to Bosma, Apland, and Kazanjian, the HPC should attend to the physical, phycosocial and spiritual aspects of death and dying, the ideal HPC provider demonstrates excellent knowledge and expertise about end-of-life care, and is respectful, genuine and compassionate; and HPC should include a range of resources that alleviate the potential burdens associated with end-of-life care. Stress on Care givers The care givers do face depression, anxiety and no regularity in eating and sleeping habits on account of their attention to the patients, and it has negative impact on their health also. They are emotionally attached to the patient and there may be guilt in their mind about perceived inadequacy in attention or helplessness or feeling responsible for the natural hardships the patient undergoes. “…family caregivers often experience the same feelings of well-being, distress, and depression as patients with a terminal cancer.” (Boyles, 2010) Professional distress Health care professions need empathy to deal with the patients and their family members. In this process they are caught into the emotional stress their patients undergo. The life and death decisions they make frequently, emergency treatments at odd times, influence of financial considerations in giving treatments and decision making and the host of other factors push them to distress both physically and mentally. Disparity among the patients on account of their financial or social status, helplessness due to financial problems of the patients or lack of family support to the patients affects them greatly as they have to face these realities on daily basis. The medical professionals are dealing with those people who are at the verge of death, and palliative therapy is not for cure in such cases. Therefore, there is a sense of failure or frustration on the part of the Doctors and Nurses. In the case of nursing, sometimes they ‘burn out’ due to stress, lack of sleep and complexities in dealing with the patients and their family members. Conclusion A comprehensive palliative care aims at providing relief from pain and distress with the intention of making the patient to lead a normal life. This is combined with the other therapies such as chemotherapy or irradiation to postpone the death. With the suffering of the end of life lung cancer patients, their family members are also distressed at the plight of the patient. For the psychosocial care to be effective, awareness among the patients and their family members should be created to overcome the barriers, and among the health care professionals for early referral. The areas related to prognosis needs to be strengthened and the enhancement of standards at all levels such as education, training, faculties and practice is necessary for a comprehensive approach to palliative care for the lung cancer patients. References Avert (2010) Definitions of Palliative Care, http://www.avert.org/palliative-care.htm Bosma, H., Apland, L. & Kazanjian, A. (2009) Review: Cultural conceptualizations of hospice palliative care: more similarities than differences, Palliat Med July 2010 vol. 24 no. 5510-522, first pub 12 Nov 2009 Boyles, S, Cancer Caregivers Share Patient Stresses, MedicineNet.com, 11 Jun 2010, http://www.medicinenet.com/script/main/art.asp?articlekey=117140 Brookshaw, K. et al. (2009) Referral and access barriers to a multi-disciplinary outpatient palliative care service, Yarra Ranges Health, Eastern Health, http://www.supportivecancercarevictoria.org/PDF/SSConf09S5KBrookshaw.pdf Brown, D. & Anda, R. (2010) Childhood Harms Can Lead to Lung Cancer, Science Daily, 19 Jan 2010. http://www.sciencedaily.com/releases/2010/01/100118204045.htm Center to Advanced Palliative Care (2008) Improving Palliative Care in Nursing homes, New York, www.capc.org Corboy, D., McLaren, S. & McDonald, J.(2009) Barriers to psychosocial support service use by men with cancer living in rural areas, University of Ballarat, Australia, 8 Dec 2009 http://www.supportivecancercarevictoria.org/PDF/SSConf09S5DCorboy.pdf Doyle, D. Hanks , G. Cherny, N. and Calman, K., (2005) Ed. The oxford text book of palliative medicine, third edition, Oxford University Press. European Men’s Health Forum, Earlier Detection of Lung Cancer (2009), Ed. Pollard, J. http://www.emhf.org/resource_images/EMHFlungcancerreport09.pdf Jeffrey. D. (2003) What do we mean by psychosocial care in palliative care, www.oup.co.uk/pdf/0-19-851540-5.pdf Lethborg, C. & Brown, (2009) R. A targeted orientation and information program for newly diagnosed cancer patients at St. Vincent’s Hospital. St. Vincent’s Hospital, http://www.supportivecancercarevictoria.org/PDF/SSConf09S5CLethborg.pdf Miller, S. (2009), CanNET National Support and Evaluation Service: Final National Evaluation Report, Cancer Service Networks National Demonstration Program, Cancer Australia, http://www.canceraustralia.gov.au/media/files/cannet/about/natl_cannet_eval_report.pdf Morrow, A.R.N. (2009) What is Pain? About.com: Palliative Care, http://dying.about.com/od/paincontrol/a/whatispain.htm National Foundation for Cancer Research (2010), Cancer Research, http://nfcr.org/index.php?option=com_content&view=article&id=453&Itemid=122&gclid=CPqB39mO6aMCFQFB6wod7DVy1g Nova Scotia Chronic Pain Working Group, (2006) ACTION PLAN For THE ORGANIZATION AND DELIVERY OF CHRONIC PAIN SERVICES IN NOVA SCOTIA, 19 Jul 2006. http://www.gov.ns.ca/health/reports/pubs/Action_Plan_Chronic_Pain.pdf Quill, T.E.& Meier, D.E. (2006), The Big Chill — Inserting the DEA into End-of-Life Care, The New England Journal of Medicine, 2006; 354:1-3 January 5, 2006, http://www.nejm.org/doi/full/10.1056/NEJMp058289 Science Codex, Lung cancer patients receiving palliative care had improved quality of life, extended survival, 18 Aug 2010, http://www.sciencecodex.com/lung_cancer_patients_receiving_palliative_care_had_improved_quality_of_life_extended_survival Wright, A.A. & Katz, I. T (2010), Letting Go of the Rope — Aggressive Treatment, Hospice Care, and Open Access, The New England Journal of Medicine, The New England Journal of Medicine, 2007; 357:324-327. July 26, 2007 http://www.nejm.org/doi/full/10.1056/NEJMp078074 World Health Organization, (2010) Palliative Care, file:///C:/Documents%20and%20Settings/ADMIN/Desktop/WHO%20%20%20Palliative%20care.htm Read More