Care of the Patient with Advanced Cancer
The patient with advanced cancer is likely to experience many of the problems previously described, but all to a greater degree. Symptoms of gastrointestinal disturbances, nutritional problems, weight loss, and cachexia make the patient more susceptible to skin breakdown, fluid and electrolyte problems, and infection.
Although not all cancer patients experience pain, those who do commonly fear that it will not be adequately treated. Although treatment at this stage of illness is likely to be palliative rather than curative, prevention and appropriate management of problems can improve the quality of the patient’s life considerably. For example, use of analgesia at set intervals rather than on an “as needed” basis usually breaks the cycle of tension and anxiety as-sociated with waiting until pain becomes so severe that pain re-lief is inadequate once the analgesic is given. Working with the patient and family, as well as with other health care providers, on a pain-management program based on the patient’s requirements frequently increases the patient’s comfort and sense of control. In addition, the dose of opioid analgesic required is often reduced as pain becomes more manageable and other medications (eg, seda-tives, tranquilizers, muscle relaxants) are added to assist in reliev-ing pain.
If the patient is a candidate for radiation therapy or surgical intervention to relieve severe pain, the consequences of these pro-cedures (eg, percutaneous nerve block, cordotomy) are explained to the patient and family, and measures are taken to prevent com-plications resulting from altered sensation, immobility, and changes in bowel and bladder function.
With the appearance of each new symptom, the patient may experience dread and fear that the disease is progressing. How-ever, one cannot assume that all symptoms are related to the can-cer. The new symptoms and problems are evaluated and treated aggressively if possible to increase the patient’s comfort and im-prove quality of life.
Weakness, immobility, fatigue, and inactivity typically occur in the advanced stages of cancer as a result of the tumor, treat-ment, inadequate nutritional intake, or shortness of breath. The nurse works with the patient to set realistic goals and to provide rest balanced with planned activities and exercise. Other measures include assisting the patient in identifying energy-conserving methods for accomplishing tasks and promoting activities that the patient values the most.
Efforts are made throughout the course of the disease to pro-vide the patient with as much control and independence as de-sired, but with assurance that support and assistance are available when needed. Additionally, the health care team works with thepatient and family to ascertain and comply with the patient’s wishes about treatment methods and care as the terminal phase of illness and death approach.
For many years, society was unable to cope appropriately with pa-tients in the most advanced stages of cancer, and patients died in acute care settings rather than at home or in facilities designed to meet their needs. The needs of patients with terminal illnesses are best met by a comprehensive multidisciplinary program that fo-cuses on quality of life, palliation of symptoms, and provision of psychosocial and spiritual support for the patient and family when cure and control of the disease are no longer possible. The concept of hospice, which originated in Great Britain, best addresses these needs. Most important, the focus of care is on the family, not just the patient. Hospice care can be provided in several settings: free-standing, hospital-based, and community or home-based settings.
Because of the high costs associated with maintaining free-standing hospices, care is often delivered by coordinating services provided by both the hospital and community. Although physiccians, social workers, clergy, dietitians, pharmacists, physical therapists, and volunteers are involved in patient care, nurses are most often the coordinators of all hospice activities. It is essential that home care and hospice nurses possess advanced skills in as-sessing and managing pain, nutrition, dyspnea, bowel dysfunc-tion, and skin impairments.
In addition, hospice programs facilitate clear communication among family members and health care providers. Most patients and families are informed of the prognosis and are encouraged to participate in decisions regarding pursuing or terminating cancer treatment. Through collaboration with other support disciplines, nurses assist patients and families to cope with changes in role identity, family structure, grief, and loss. Hospice nurses are ac-tively involved in bereavement counseling. In many instances, family support for survivors continues for about 1 year.