Palliative Care with Terminal Cancer - Essay Example

?Terminal Cancer – Palliative Care Clinical The patient is a 67-year old Caucasian woman with a history of breast cancer. She first presented with breast cancer eight years ago, which successfully went into remissions after a round of radiotherapy. However, the cancer returned and upon initial diagnosis had metastasized to the lungs, bones and liver. The patient underwent several rounds of chemotherapy with little improvement. Prognosis is extremely poor for this patient due to the metastasis and the non-response to traditional chemotherapy, and therefore she has been given a terminal diagnosis. The current symptoms of the patient vary from day-to-day. The metastasis to the bone means that the client has progressive pain which is generally worsening. The liver metastasis has caused a loss of appetite, nausea and occasional bouts of very severe abdominal pain. The patient also has a chronic cough which is thought to originate from lung metastases, and will occasionally complain of chest pain. This has been confirmed by an abnormal chest X-ray. Overall, the patient has expressed dissatisfaction and at times feels unable to enjoy life, with an overall feeling of ‘sadness’. The patient also claims to have difficulty remembering some things, which is a common symptom of terminal cancers in general (Karabulu et al, 2010). Pain as a Symptom One of the most distressing symptoms for the patient, as with many terminal cancer clients, is the pain and the anxiety which comes from fear of increasing amounts of pain. Pain management is important in terminal cancer, but is not always effective. Hemming & Maher (2005) examined the management of pain and the difficulties which arise. The article highlights the fact that terminal cancer patients often have pain coming from many areas of the body, as seen in our case study above. Bone and nerve pain arising from metastases may be causing extreme pain, which is more difficult to treat. Hemming & Maher (2005) also highlight the fact that pain may be holistic, whereas treatments tend to focus purely on treating physiological pain with analgesics and other pharmaceuticals. The article also notes that pain is an extremely complex system and the mechanisms of this are not completely understood, again making pain management an extremely difficult process. Hemming & Maher (2005) examine the multiple ways in which pain should be approached. Firstly, they highlight the understanding of different types of pain; somatic, visceral, neuropathic and bone. Knowledge of this can help appropriate pain management systems to be correctly found. There is also an importance placed on the spiritual elements of the pain, which Hemming & Maher (2005) suggest need to be approached simultaneously with the more traditional physical approach. From here, the attending clinician could use an ABCDE of assessment of the pain to help them understand the location and type of pain, again helping to highlight what type of pain management may be necessary. Pharmaceutical interventions can then be considered. This should be approached in three ways. Firstly, ‘by the ladder’, which means that treatment should start from the non-opiod option and become progressively stronger by need. The article also highlights the importance of giving pain medications ‘by the clock’, or regularly, to maintain relief. Finally, Hemming & Maher (2005) advocate that pain relief be given ‘by the mouth’ through oral administration. Lynch & Abrahm (2002) focused on the Dana-Farber Cancer Institute and their approach to pain management in terminal patients. The approach here was done in a number of steps. The first of these involved assessment, with the Dana-Farber Cancer Institute advocating using numeric, verbal and a Wong-Baker-like FACES scale to judge the standard of pain of the individual. After this, patient education is conducted. The patient should be knowledgeable about the medication and approaches to pain that they are taking, particularly as a fear of addiction and the problems with side-effects are often a barrier to a patient correctly taking pain management steps. The article, similarly to Hemming & Maher (2005), also highlights the difficulty in dealing with pain as it is a complex symptom. Lynch & Abrahm (2002) suggest that pain management is an integral part of any palliative care program because it is one of the most destructive elements of terminal cancer and is often one of the things that patients are most fearful of when hearing the diagnosis of cancer. Quality of Life in Palliative Care Improving the quality of life for a patient is the most important part of palliative care. A study by Chui et al (2009) looked at the factors that impact the quality of life in palliative care patients. The paper had three main aims; to assess the quality of life and physical functioning of terminal patients, to determine if there is a relationship between physical functioning and perceived quality of life, and to assess the variables that are associated with quality of life standards. The paper assessed 300 patients with advanced stage cancer were recruited from four hospitals in Hong Kong. The quality of life and physical functioning of these patients was assessed using a face-to-face interview, the McGill Quality of Life Questionnaire (Hong Kong version) and the Palliative Performance Scale. The results of this research were interesting. The participants in general reported difficulties with walking and an inability to continue with hobbies that they had previously enjoyed. Some patients needed occasional help with housework and other daily activities. The quality of life recorded was generally fair, with a mean of 64.6 recorded out of a maximum of 100. Those with lower levels of physical functioning were found to have a slightly lower quality of life rating, as the two were weakly correlated. Interestingly, several factors were identified that affected quality of life. Scores were likely to be higher if the patient was female, had ever been married, were older and had higher physical functioning scores. These suggest that there are many aspects of the quality of life of end-stage patients that is out of the control of the treating clinicians, an interesting finding. Axelsson & Sjoden (1998) examined the quality of life for patients and their spouses in palliative care. In this study, 37 patients who were receiving help from a palliative-care service were assessed on a monthly basis to examine their quality of life over time. This was done using the assessment of quality of life at the end of life instrument. The study found that the lowest ratings were found in the last six weeks and were due to several factors. Low quality of life was found in patients who could not do what they want due to physical restraints on their activity from the cancer and the various treatments they were receiving. Secondly, quality of life was affected by their physical strength, with low values being correlated, as in the Chui et al (2009) study. Axelsson & Sjoden (1998) also found that meaningfulness was a factor in low quality of life, with patients questioning their lives and their purpose having extremely low QoL scores. Interestingly, the patients themselves were less anxious than their spouses. Spouses with lower quality of life scores were found to be affected by the patient’s ability to dress and bathe themselves. They were also affected by their own ability to leave the patient unattended and overall anxiety. Meaninglessness had the highest impact on both the patient and the spouse overall, suggesting that psychological symptoms and holistic care are very important in palliative care. Axelsson & Sjoden (1998) suggested that a more holistic and ambitious approach should be used to improve the quality of life of these patients as there are a number of factors highlighted that are not necessarily targeted as standard practise. Evidence-Based Interventions From the research above, it seems evident that palliative care requires a more holistic approach and should deal with a number of aspects that affect the patient’s quality of life. This brings the need for complementary or alternative medicine into question. Ernst, Filshie & Hardy (2003) put forward some interesting opinions of complementary medicine which should be taken into account when using this as the basis for an evidence-based intervention. The first is that these medicines often have not undergone a rigorous scientific trial, which means that there may be some contra-indications with other medications. They may also have extreme side-effects which could cause the patient more pain than is necessary. However, there is some evidence that alternative medicines can be effective in curing some symptoms of end-stage terminal cancer, which means that they should not be overlooked by medicine completely. Complementary medicines may also help to deal with some of the psychological and psychosomatic elements of pain, which could make them useless as it has been identified that pain is an extremely complex symptom. For this reason, it would be recommended that the patient identified in the clinical study should undergo some alternative medicine of their own choosing, provided they think it will be beneficial. This could include, but is not limited to, homeopathy, alterative medications, acupuncture or massage. These may have no meaningful physical effect but could have some positive implications for the mental health of the patient and the amount of pain that they are experiencing. When it comes to pharmaceutical pain management, there are a number of approaches that can be taken. Hemming & Maher (2005) suggest that three approaches need to be taken, and these are applicable to this patient. Firstly, ‘by the ladder’; gradually increasing the pain management drugs until a suitable solution is found. The patient can try increasing strengths of painkillers until one is found that is suitable. This should start from the non-opiods. Any side-effects should be noted to ensure that the right choice is made by the patient. As the patient is still able to take things by mouth, ‘by the mouth’ is applicable here. All medication should be given by mouth as this is generally the preferred method for patients and works well. When the client can no longer taken medication by the mouth, the rectal route has been found to be very effective in administration (Hemming & Maher, 2005) although this should be a last resort as patients find this very uncomfortable. ‘By the clock’ should also be adhered to as it is important to be regular with the medications. It would also be beneficial to continually monitor the pain levels of the patient (Portenoy & Lesage, 1999). Palliative Care for the Client Palliative care needs to place the needs of the patient first and ensure that their quality of life is maximised through their last days. As the patient in the clinical case above is suffering from metastatic breast cancer, one of the most important issues for her is dealing with the pain. As the cancer has spread to her bones, this pain can often be deep and constant, so it is important for the patient to ensure that this is managed effectively. There are a number of other sources of pain to the individual, not least of which come from psychological feelings of anxiety regarding her prognosis and feelings of hopelessness and sadness. These too need to be dealt with as part of an effective palliative care program because many of the symptoms of physiological pain may be aggravated by these psychological variables, as shown in the research above. Perhaps the most important reason why I would recommend palliative care for this patient is that terminal cancer can be a terrifying and painful process. With a limited amount of time left, it is important that the quality of life be maximised throughout these days. This is beneficial not only to the patient, but to their friends and family who may also be having difficulties dealing with the prognosis and the feelings of hopelessness. References Axelsson, B., & Sjoden, P. O. (1998). Quality of life of cancer patients and their spouses in palliative home care. Palliative Medicine, 12(1), 29–39. Chui, Y. Y., Kuan, H. Y., Fu, I. C. ., Liu, R. K. ., Sham, M. K., & Lau, K. S. (2009). Factors associated with lower quality of life among patients receiving palliative care. Journal of advanced nursing, 65(9), 1860–1871. Ernst, E., Filshie, J., & Hardy, J. (2003). Evidence-based complementary medicine for palliative cancer care: does it make sense? Palliative medicine, 17(8), 704–707. Hemming, L., & Maher, D. (2005). Cancer pain in palliative care: why is management so difficult? British journal of community nursing, 10(8), 362. Karabulu, N., Erci, B., Ozer, N., & Ozdemir, S. (2010). Symptom clusters and experiences of patients with cancer. Journal of advanced nursing, 66(5), 1011–1021. Portenoy, R. K., & Lesage, P. (1999). Management of cancer pain. The lancet, 353(9165), 1695–1700. Read More