Pathophysiology Progressive Condition and End-of-Life Debate - Research Paper Example

? Pathophysiology of a Progressive Condition & End-of-Life Debate By School 25th March Breast cancer is one of the most common cancerscausing almost 7% of all cancer deaths and 2% of all deaths in the United States (Coughlin & Ekwueme, 2009). Although many people consider breast cancer as the type of cancer that purely affects women, this is not the case, as men can also develop breast cancer and complications. Many people also believe breast cancer affects only the breast tissue until the unfortunate situation of metastasis. There are many cases in which breast cancer and metastasis can affect a number of other systems, including the brain, liver and bone tissues. The purpose of this paper is to explore the pathophysiology of breast cancer and its effects on the breast tissue. The paper will also explore how breast cancer is a progressive condition and can begin to effect systems, including those mentioned above, and should not be viewed as solely a female mammary tissue problem. It is important to consider these metastases because they can dictate what is necessary for treatment procedures, and render surgery and radiotherapy unnecessary (Gavrilovic & Posner, 2005). This paper will also examine the pros and cons of end-of-life care for these patients and the reasoning behind the decision of not resuscitating in breast cancer cases. These will all be examined with the purpose of showing the difficulties that clinical staffs face in dealing with breast cancer patients, their metastases and their end-of-life care decisions. Client Scenario A 37-year old woman has had recurring metastatic breast cancer for the last nine years. The first diagnosis was node-positive in the right hand side of her body, which was treated by mastectomy. Following this, cancer was still present in the body and radiation treatment was given to the client. The client went into remission, but the cancer returned and was treated with chemotherapy; doxorubicin, fluorouracil, and cyclophosphamide. The treatment appeared successful. Six months ago, the patient presented with bone pain, fatigue and a lump in the left breast. After analysis, it was found that the cancer was present in the breast and had metastasized to the bone, brain and liver, and is thus diagnosed with having end stage cancer and no chance of remission. The patient shows anxiety and depression at the diagnosis, particularly as she has two young children. There have been requests that treatment be stopped to prevent the patient from extended pain. Presenting and Progressive Signs and Symptoms One of the most common signs of breast cancer is a lump in the breast, although other changes in the breast tissue such as thickening, changes in colour and swelling are also reported (Yarbro, Wujcik & Gobel, 2011). The breast can also show signs of pain, although breast pain is common in women and should not be confused with breast cancer. As the disease progresses and metastasizes, a number of other symptoms can be seen. For bone metastases, the patient can expect to feel bone pain. Other symptoms of bone metastases include breakages in the bone due to weakened bone tissue and hypercalcemia (Costelloe et al., 2009), which would be picked up by routine examination. Breast carcinomas can also metastasize to the brain. The signs of a secondary brain tumour are numerous, and include consistent headache, changes in vision, seizures, stroke or brain haemorrhage, changes in mental status, difficulty with speech or other everyday actions, confusion, loss of control, uncontrolled bladder or bowel movements, back pain, more generalized pain, weakness, vomiting and nausea, double vision, slurred speech, and anxiety (Gavrilovic & Posner, 2005). Finally, breast cancer can also metastasize to the liver. Signs that this has occurred include anorexia, confusion, fevers, nausea and weight loss (Yarbro, Wujcik & Gobel, 2011). Pathophysiological Causes of Breast Cancer All cancers have similar mechanisms in the way that they develop. All cancers are genetic in that a mutation or fault in a gene is the reason why the cells can no longer undergo apoptosis and continue to multiply. Most cancers are sporadic rather than genetic, although there are important developments being made in the identification and analysis of hereditary oncogenes for breast cancer in particular. Carcinogenesis There are usually no easily identified causes for sporadic cancers, although the general mechanisms are known. Cell division and replication are controlled by two important groups of genes, the proto-oncogenes and the tumour suppressor genes, with are kept in a homeostatic balance. A mutation that stops the tumour suppressor gene carrying out a control function may lead to cancerous growths, and a mutation in a proto-oncogene that causes increased expression could have the same result (Ruddon, 2007). Although the majority of cancers are sporadic, some genes for cancer have been getting a huge amount of media and academic attention. Around 2-3% of all patients with breast or ovarian cancer have a BRCA mutation (Coughlin & Ekwueme, 2009). Having this mutation does not necessarily mean you will develop breast or ovarian cancer, but there is a hugely increased risk, and 60-80% of patients with the mutation will develop breast cancer, hence it being hugely important in medicine. The BRCA mutations are associated with interference with DNA repair mechanisms, meaning that they contribute in some way to the uncontrolled growth characteristic of carcinomas (Ruddon, 2007). Metastasis to Other Systems Metastasis to other organs is a complex process that can occur in a number of ways. For metastasis to occur, malignant cells need to break off from the original tumour and express proteins that degrade the extracellular matrix to enter the blood or lymphatic system (Yarbro, Wujcik & Gobel, 2011). Metastasis also requires growth of a new network of blood vessels, which is a process known as angiogenesis (Gavrilovic & Posner, 2005). Metastasis can be transcoelemic, through lymphatic or hematogenous routes, or by transplantation. In the case of breast cancer, the most common organs for metastasis are the liver, bone, lung and brain (Lacroix, 2006). Metastasis dramatically decreases the chance of patient survival (Yarbro, Wujcik & Gobel, 2011), and in turn increase the likelihood of further metastases. The secondary tumours often disrupt the normal working process of the organ, leading to the symptoms described above. The Impact of Care Breast cancer is the most common invasive cancer in women (Coughlin & Ekwueme, 2009), making it one of the most important cancers to understand, treat and diagnose. Around 12% of women in the United States will develop breast cancer at some point in their lives (Coughlin & Ekwueme, 2009), a statistic that looks as something set to grow as the population ages. Although a disease being common does not necessarily make it important, the fact that breast cancer is so dangerous and has a high mortality rate ensure that practitioners need to have a good understanding of the causes and treatment of the disease. Metastases are less common, but are even more dangerous than primary breast carcinomas (Yarbro, Wujcik & Gobel, 2011), which make it important to learn about the routes of care for these patients and how best to improve their quality of life during the process of care. Nurses need to carry out a number of functions when dealing with breast cancer patients. The first point of call is telling the patient of their diagnosis, an extremely difficult and upsetting process that needs to be dealt with professionally and compassionately (Yarbro, Wujcik & Gobel, 2011). The nurse could also advise the patient on the treatment options and support them in their decisions, ensuring that the patient understands that cancer treatment is gruelling and lengthy (Windsor, Potter, McAdam & McCowen, 2005). An increasingly important aspect of the breast nurses role is to advise about mastectomy and the different ways in which a breast can be reconstructed, an important part of maintaining a female patients’ self-esteem. Perhaps the most difficult part of the job is dealing with patients such as those described above. The case study describes a female whose breast cancer has metastasized to the bone, brain and liver, which makes it very unlikely that she will survive. The nurse in this role has to advise about treatment, as well as answering questions about death and helping patients in end-of-life care (Yarbro, Wujcik & Gobel, 2011). As with other progressive diseases, it is important for a nurse to provide holistic care, incorporating family members as well as focusing on the mental health of the patient (Wright et al., 2008). The impact on nursing from cancers is huge, partly due to the life-changing nature of the disease and partly because of the wide range of treatment options and support services available. Ethical Decisions The patient described above has a severe progression of the breast carcinoma to the lung, brain and liver, which means that she has been given a terminal diagnosis. In this case, there are a number of ethical issues that can be addressed, particularly by the nurse who is dealing with an emotional and stressed patient. The two main options for a terminal cancer patient are to continue with treatment with the hope of keeping the cancer symptoms reduced and to prolong life, or to finish all treatment to avoid the negative effects of chemotherapy and radiation. The first option is generally encourage, as although cancer treatments can be unpleasant, many patients want to live their life as long as possible to fit in as much as they can before the end of their life. Many patients also go down this route in the hope that there may be some ‘miracle’ cure or remission (Yarbro, Wujcik & Gobel, 2011), which is always a possibility that needs to be considered. There are a number of ethical dilemmas here. The patient ultimately has the choice to make their own decisions about healthcare. Brain metastases may complicate this if there is some change in thought processes, but generally terminal cancer patients remain mentally competent enough to make their own decisions. A nurse’s role is to advise on the decision-making, and as the nurse is involved at all stages of care there are definitely some considerations to be made morally. The first point is that the practitioner may feel that their role is to provide healthcare and help the patient to live the longest life possible (Johnstone, 2012). This means that the patient should undergo as much treatment and therapy as possible to reach this goal, even if the treatment is invasive or upsetting. Conversely, some may see their role in the healthcare sector as promoting health and a ‘good death’, ensuring that a patient retains dignity and as much happiness as possible through to the end of their life (Johnstone, 2012). In this case, the patient has an inevitable death which means that the focus for these people is ensuring that the last days of the patient are as pain-free and happy as possible. The problem with chemotherapy and other cancer treatments is that they have a number of side-effects, including extreme nausea and vomiting, hair loss and fatigue (Yarbro, Wujcik & Gobel, 2011), which make them a daunting prospect. The patient may feel that they are terminal and therefore any treatment that prolongs their life in this way is unnecessary and may be a detriment to their happiness in their last days. Morally, it seems that this is the best route to go down if the patient wishes to end their life in this way, particularly as a nurse can provide other elements of palliative care to reduce the pain and suffering from the cancer which have less side-effects than traditional cancer treatments (Yarbro, Wujcik & Gobel, 2011). The most ethical stance on this matter involves listening to the patient and giving them and their family members as much advice as possible to help them to make the decision that is most right for them. There are a number of pros and cons to each side, as briefly outlined above, but the most positive way of providing care for end-of-life patients is to provide them with what they want. Many patients with young children opt to extend their life despite the pain of chemotherapy (Johnstone, 2012), because they would like to experience as much of their child’s life as possible. Many patients in the later stages of their life are more mentally prepared for death and are more likely to choose the option of a faster death to avoid the pain of the cancer treatment drugs (Shepard, 2010). Something else which is important ethically is for the clinical team to make sure that all options have been exhausted before considering a terminal diagnosis. The case study above concerns a woman with a recurring case of breast cancer as well as three sites of metastases. She has undergone chemotherapy, radiation and surgery, and her cancer is evidently terminal. In some cases, patients may wish to try alternative medications or therapies, and the decision must be made whether the cancer is terminal, as stopping treatment at this stage could be fatal (Shepard, 2010). Again, the ethical decision needs to take into account the likelihood of a ‘miracle’ remission or the development of new treatments in the lifespan of the patient and advise them on their decision (Johnstone, 2012). Conclusions and Justifications Evidently, there are a number of things to consider in end-of-life care. The most important thing is to inform the patient about the possible decisions and the consequences that this will have, as morally and legally the patient has the final say on the decisions about their healthcare. This means that the nurse and other members of the clinical team need to know as much as possible about the diagnosis of the patient to help them make an informed decision (Johnstone, 2012). Probably the worst thing to do in this situation morally is to provide the patient with bad information, potentially leading to the death of a patient who had a chance to be saved. It is extremely difficult to make a decision about end-of-life care without knowing the opinions and lifestyle of the patient, particularly if they have certain religious beliefs that need to be carefully adhered to. There is no way of knowing which decision is best for the scenario, although as the case study above involves a woman with children she may wish to continue her life for their sake, as we have seen. The moral duty of the practitioner in this case is to provide the patient with the best possible care to match their personal decisions about the matter. Evidently, breast cancer is a terrible disease with a lot of possible pathophysiological points that are complex in nature. Breast cancer can become a progressive disease that metastasizes to a number of other organs or tissues, including the brain, bone and liver. This means that the nurse needs to be prepared for the end-of-life decisions that need to be made when the cancer becomes terminal. The best thing to do in this situation is to advise the patient and then adhere to their wishes whether it is for treatment to extend their life or stopping treatment to avoid the side-effects. The number one priority is the patient, who has a right to choose their own healthcare and make their own decisions, and the best thing to do morally is to listen to their wishes and hope that the end of their life is as pleasant as possible. References Costelloe, C. M., Rohren, E. M., Madewell, J. E., Hamaoka, T., Theriault, R. L., Yu, T. K., Lewis, V. O., et al. (2009). Imaging bone metastases in breast cancer: Techniques and recommendations for diagnosis. The Lancet Oncology, 10(6), 606–614. Coughlin, S. S., & Ekwueme, D. 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