SELF INSTRUCTIONAL MODULE ON PALLIATIVE CARE FOR CANCER PATIENTS Introduction Palliative care is active total care of patients

with life limiting diseases and their families by a multi-disciplinary health team, when the disease is no longer respond to curative or life prolonging treatments. Palliative care uses a team approach to address the needs of patients and their families. It begins early in the course of illness in conjunction with other therapies. Nurses play an important role as members of the health care team to provide care to cancer patients and their families, throughout their life. Definition of Palliative Care for Cancer Patients (WHO 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 e.g. physical, psychosocial and spiritual. Goal of Palliative Care The goal of palliative care is achievement of the best possible quality of life for patients and their families. Aims of Palliative Care 1. Affirms life and regards dying as a normal process. 2. Neither hastens nor postpones death. 3. Provides relief from pain and other distressing symptoms. 4. Integrates psychological and spiritual aspects of care. 5. Offers a support system to help patients to live as actively as possible until death. 6. Offers a support system to help the family to cope, during patients illness and their bereavement. Principles of palliative care 1. The fundamental principle is patient and family together comprises the unit of care. 2.Diagnostic and invasive procedures are minimized. 3.Care is individualized and based on the goals of patient and the family. Indications of Palliative Care Any terminally ill cancer person irrespective of their diagnosis can receive palliative care. Palliative care may be delivered in home care settings or in hospitals. Palliative care starts from diagnosis and continues till the death of the patient. Palliative care team Palliative care is best given by a group of people working as a health care team. It consists of Doctor Nurses Physiotherapist Occupational therapist Social workers Volunteers Counselor Patients Families Importance of nurses role in palliative care Nurse becomes the vital corner stone of the health care team. Nursing staff make a major contribution to the success of the team because they are the continuous care givers. The nurse becomes the nucleus of the health care team because of the following reasons. The nurse in palliative care team - Must work co-operatively and communicate effectively with other team members. - Must take initiative in the role as care giver, educator and consultant. - Must co-ordinate care and services provided to the patient and their families. - Must be able to provide physical, emotional, social and spiritual care. - Promote a relaxed relationship with the patient, family and other team members. - Promote confidence in achieving goals of the care.

PAIN
Up to 90% cancer patients experience pain. Patients with advanced cancer experience severe pain and that pain occurs in 30% of all cancer patients, regardless of the stage of the disease. It is the most common symptoms in patients requiring palliative care. Pain is what the patient says hurt. Cancer pain is of chronic type in nature. Pain is the result of a physiological series of electrical and chemical events that occur in the body. International Association of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." Pain is always subjective. Total pain includes physical, social, emotional and spiritual factors which affect both patient as well as family. Physical pain Nausea, vomiting and constipation. Adverse effects of treatment e.g chemotherapy/ radiatiotherapy. Insomnia and chronic fatigue. Emotional pain Fear of loss of job. Uncertainty about future life. Fear of death. Spiritual pain: Feelings like Why has this happened? Why God allowed me to suffer? How can I be forgiven? Is there any meaning in my life? Social pain Worry about family and finances. Loss of job and prestige. Causes of pain Pain from the tumor. Most cancer pain occurs when a tumor presses on bone, nerves, or body organs, and may vary according to location, (i.e., a small tumor pressing on a nerve or vital organ may cause severe pain, while a larger tumor elsewhere may cause little discomfort.) Pain from cancer treatment. Like surgery. Pain from other causes. Like everyone else, cancer patients have pain that has no relationship to their illness. Headaches, muscles strains, or other aches and pains associated with arthritis, kidney stones, etc., may cause pain. These conditions can normally be treated along with cancer pain. Pain due to anxiety over the outcome is also called mental pain. Combination of physical pain and mental pain increases the intensity of pain. Nursing role in managing pain Setting goals Set realistic goals such as a) Enabling the patient to be pain free at rest. b) Enabling the patient to sleep well at night. Pain assessment: is an essential part of nursing care. The nurse must investigate into the relevant factors. Site: where is the pain? Origin: where does it start? Character: what kind of pain? (Dull, shooting, persistent or intermittent) Radiation: Does it radiate? Alleviating: What relieves the pain? Time course: How long does it last?

Exacerbating factors: what makes it worse? Severity: How severe is it? Identifying sites of pain Body chart is used to identify the sites of pain and is best filled by the patient. Pain measurement Different scales are used to measure the intensity of pain. The nurse will need to identify the most suitable one for the individual patient. a) By visual analogue scale: it is 0-10cm scale. Patient is asked to indicate the intensity of pain by marking on the scale. b) By face scale: a set of faces can be used to indicate the severity of pain. c) Simple descriptive pain intensity scale Principles of drug interventions to reduce pain a) By mouth: oral route is the preferred route for analgesics including morphine. b) By the clock: for persistent pain, drug should be given at regular time and not as needed. c) By the ladder: WHO three step analgesic ladder Step 1 for mild pain: use of non-opioid analgesics. Step 2 for moderate pain: analgesics used are weak opioids and are given in addition to the nonopioid. Step 3 for severe pain: strong opioids are given by mouth. If patients are not able to take oral medication, strong opioids are given by other route. Drugs used in analgesic ladder NSAIDS: Asprin, Ibubrofen, Naproxen, Indomethacin. Weak opioids: Codeine, Diamorphine Strong opioids: Morphine, Methodone, Buprenorphine. Side effects of morphine At the beginning Continuing Occasional Vomiting Constipation Dry mouth Drowsiness Sweating Unsteadiness Confusion Adjuvant drugs and their use: Adjuvant drugs are co-analgesics which are given along with opioid and non-opioid analgesics when some pain does not respond to opioids eg bone pain, nerve pain. Commonly used adjuvant drugs are NSAID, Corticosteroids, Antidepressants and antiarrythmics. Complementary therapies used in pain relief These are non-pharmacological pain management which eliminate or reduce the cause of pain or increase pain tolerance. They are as follows: a) Relaxation techniques like making the patient as comfortable as possible and instructing them to close the eyes and breathe rhythmically and deeply. b) Therapeutic touch e.g. applying garlic ointment helps to reduce muscle spasm and distracts the patient. c) Massage with herbal oils e.g. lavender oil for headache or muscular pain. d) Use of visual images such as showing patients a series of pictures likely to interest them. e) Acupuncture: pricking the body with needles to relieve pain. f) Acupressure: pressing the body at specific points to relieve pain g) Yoga and meditation reduce stress and promote relaxation. Nursing interventions in pain relief Listen the complaints of the patients. Assess patients fears and anxiety.

 Accept the patients pain. Be with the patient. Never leave the patient alone. Allow the patient to express their feelings. Prevent isolation and loneliness by allowing the family members to be with the patient. Give relaxation therapies. Report the symptoms to the doctor. Check doctors order and give prescribed medications. Change the position of the patient as possible. Give gentle massage with herbal oil. Apply hot or cold compresses to the painful body part. Use bed cradles, foot rest when needed to take away the weight of blankets. Clean the wound and keep the patient free from mal odour. Relieve boredom by diversional therapies like music, playing chess etc. Allow relatives to talk with the patient. Occupational therapy as per the patients ability to perform. Provide material to the patient for knitting, stitching and doing craft works etc. Provide books, newspapers, magazines for reading. Ambulate the patients with the help of wheelchair for better change.

2. NAUSEA AND VOMITING

Nausea and vomiting are common and distressing symptoms in patients receiving palliative care for advanced cancer and the effective management of these symptoms can make a major contribution to improving quality of life in these patients. The prevalence of nausea is 20-30% in all patients with advanced cancer and this rises to 70% in the last week of life. Causes of nausea and vomiting Malodor, Constipation, Intestinal obstruction, increased intra-cranial pressure, Gastric outlet obstruction Treatment The treatment is focus on prevention. To effectively block the neurotransmitters from stimulating the chemoreceptor trigger zone, the medications must be given before the administration of the chemotherapeutic agents. Antiemetics Drugs Drug Action Ondansetron Serotonin 5-HT receptor blocker Lorazepam Depress CNS Metoclopramide Blocks dopamine and also stimulates upper GI tract motility to increase gastric emptying. Prochlorperazinne Inhibits dopamine Nurses role in relieving nausea and vomiting Identify triggers of nausea by questioning. Keep the patients room airy and free of odors. Prevent unpleasant sights. Administer antiemetic eg Perinorm or as prescribed. Avoid foods with a strong smell. Offer small and frequent meals. Do not force or hurry eating.

 Encourage fluids like lemon or apple juice to drink if tolerating. Maintain upright or fowlers position while eating to prevent esophageal reflux. Provide suitable diversional therapy like music, painting etc. Relieve patients pain. Relieve constipation if present. Maintaining daily intake and output chart. Measure and record body weight. 3. CONSTIPATION Constipation if not treated in time, it may lead to many complications like abdominal pain, intestinal obstruction, urinary dysfunction, overflow diarrhea and vomiting. Causes of constipation Constipation is often caused by variety of factors most of which are reversible. Cancer related: intestinal obstruction Situational: lack of privacy Treatment related: opiods, tricyclic depressant, aluminium containing antacids Illness related: decreased physical activity, physical weakness, decreased food intake, dehydration and increased intake of liquid diet, hypercalcemia. Nurses role in relieving constipation Preventive measures: review bowel habits of each cancer patient every alternate day. Nursing interventions: Administer laxatives as prescribed e.g isbagol with warm milk H.S daily. Relieve pain. Encourage high fiber diet and fluids as tolerated by the patient. Increase physical activity as tolerable to the patient. Provide adequate privacy by using screens for using English toilets. Use portable bed side commode Avoid using bed pans, as it causes embarrassment and discomfort to patients. 4. ANOREXIA AND CACHEXIA Anorexia and cachexia are the common features of advanced cancer generally occurring together as anorexia-cachexia syndrome. Cancer cachexia is related to inadequate nutritional intake along with increasing metabolic demand, increased energy expenditure due to anaerobic metabolism of the tumor cells for nutrients. Causes of anorexia Malodor of food, altered taste due to chemotherapy, nausea, vomiting, delayed gastric emptying, sores in the mouth and throat, pain and constipation. Causes of cachexia Vomiting, diarrhea, malabsorption, decreased food intake, loss of body protein, abnormally metabolism of tumor products, intensive radiotherapy, intensive chemotherapy Nurses role in managing anorexia and cachexia Provide nourishing food according to the taste and as tolerated by the patient. Provide food as per likes and dislikes of the patient. Modify the diet to suit the individual eg grinding foods to make semisolid form. Serve the food at the right temperature. Serve the food in small portion in small plates at frequent intervals. Encourage the patient eat with others. Facilitate the patient to sit while eating if possible or provide back rest.

 Give mouth washes before and after each meal. To improve taste of the food use agents like hara-dhania, pudhina, nimbu, illaichi, etc.

Avoid spicy and irritating foods. Maintain daily intake output chart. Measure and record body weight weekly. 5. SKIN PROBLEMS Care of the skin is essential because patients with cancer in the terminal stage often become much debilitated. Common skin problems are pressure sores and fungating lesions. Fungating lesions occur when cancer infiltrate the epithelium. Risk factors a) Patients with anorexia-cachexia syndrome results in decreased body immunity. b) Patient with incontinence of urine, feces or high fever. c) Patients with edema d) Bed ridden patients. Nurses role in prevention of Skin Problems Examine skin over all the bony prominences at least once a day. Clean the skin over bony prominences with soap and water. Give regular back care 4 hourly. Use moisturizer to keep the skin soft. Change the position every 2 hourly. Mobility of the patient to be improved if possible. Do not drag the patient; always lift the patient while changing the position. Train the patients relatives to change the position of the patient. Bed clothes should be loose to allow spontaneous movement. Avoid nursing the patient on hard surfaces. Use alternate air or water mattress if possible or use air cushion or rings. Avoid creases in bed sheets and provide clean, dry wrinkled free bed. Urine and or feces should be cleaned immediately if the bed is soiled. Nurses role in managing fungating lesions Keep the decubitis ulcer or fungating lesions as clean as possible. Daily change the dressing and cover the pressure sores with sterile dressing pads. Clean the wound with half strength eusole or hydrogen peroxide followed by normal saline to remove the necrotic tissues. Expose the wound to ultra violet rays. Use sterile absorbable dressing material. Use dressing material which does not stick to the wound. Use sterile vaseline gauge to prevent sticking to wound. Apply metronidazole ointment to the fungating lesions. Apply a pad soaked in adrenaline 1:1000 if capillary bleeding is present. Give gentle physiotherapy to the part affected by the wound. 6. DYSPNEA Breathlessness is a distressing symptom experienced by about two third of patients with bronchogenic carcinoma and nearly one third of patients with terminal cancer of any origin. Dyspnea is defined as the unpleasant sensation or awareness of difficult or labored breathing. Dyspnea should be distinguished from tachypnea (increased respiratory rate) and hyperpnea (increased depth of ventilation).

Causes of dyspnea Obstruction of bronchus, Chemotherapy fibrosis, Radiation fibrosis, Anemia, Cancer of lung tissue, abdominal distension, Pleural effusion Nurses role in relieving dyspnea Provide correct positioning of the patient i.e semi-fowlers position. Relieve pain by administering opioid. Explain and reassure the patient to reduce anxiety/ stress. - Encourage the patients to express their feelings. - Explain calmly to promote mental rest. - Reassure that breathlessness in itself is not dangerous. Provide plenty of space around the bed. Open nearby window to provide well ventilated room. Teach patterns of breathing to reduce dyspnea and anxiety eg regular, slow, deep breathing exercise. Tell the patient to avoid over exertion to promote physical rest. Administer O2 by nasal prongs or mask if patient feels comfortable. Observe the patient for cyanosis, respiratory rate and depth and comfort. 7. PSYCHOSOCIAL ASPECTS Psychological needs are common to cancer patients in all cultures. Serious problems of anxiety and depression commonly occur in cancer patients. Psychosocial problems not only affect the patients; their families are also affected. Care should also focus on assisting families to cope with situations. Nurses role in meeting psychosocial needs a) Need for safety: always be with patient; never leave the patient alone. - attend the patients request promptly. Never say I will back in a minute unless it is true. b) Need for Belonging: accept the way patients behave. Encourage to express their thoughts and feelings. c) Need for Love: be kind and polite. Use therapeutic touch. d) Need for understanding: explain the symptoms and the nature of disease. Give opportunity to discuss the process of dying if patient wants to discuss. e) Need for Acceptance: accept the patients as they are. Do not be judgemental. f) Need for Self-esteem: involve the patient in decision making regarding his care, diet and treatment. g) Need for Trust: communicate honestly with the patient and his family members and care givers. Gain their confidence by giving the best possible care. h) Need for Respect: respect the persons needs for independence by allowing to do what the patient can do for himself or herself or in refusing care such as turning and feeding. Pay due respect to the religion of your patients. Nurses role in involving family members in care Always introduce yourself to the patient. Give each family member an opportunity to speak. Encourage the family to include children in the care. Find out whether family has experienced this kind of problem before. Find out whether family has any other problem at that moment. Encourage family members to remain near the patient and assist in meeting his/her basic needs. Teach the family members to understand the condition and provide care. Never criticize familys behavior. Accept family members feeling of anger, grief, other emotions and reactions.

 Inform the family members that uncomfortable feelings such as guilt, anger and resentment are

normal in their situation. Involve the family members in the care of their cancer patients that are appropriate to their level of knowledge and skill. 8. SPIRITUAL ASPECTS Because palliative care is concerned with the well being of the whole person, it should acknowledge and respect the spiritual aspects of human life. Spiritual needs of a patient a) The need for meaning and purpose of support. b) The need to be loved and have harmonious relationship. c) The need for forgiveness. d) The need for hope and strength. e) The need for trust in god. f) The need to express spiritual beliefs, values and practices. g) The need for a concept of God. Nurses role in meeting spiritual needs Counsel and pray with the patients. Assist them feel valued by encouraging expression of their thoughts, wishes and needs. Assist the patient feel less lonely by exploring their past, present and achievements and future plans. Assist the patient in meeting his spiritual needs e.g. playing religious music or arranging visits by the religious preacher. ETHICAL CONSIDERATIONS Introduction There must be an acceptable balance between the advantages and disadvantages of the cancer treatment. Nurses must take care that to do good to the cancer patient and to minimize causing harm to the cancer patient. The main principles applied in palliative care are: I. Respect for life: Nurses must take all reasonable means to protect and sustain human life when there is hope for recovery or when the cancer patients can get benefit from life prolonging treatment. II. Respect for patient autonomy: The patients have the right to decide and nurses must carefully determine the patients values. III. Fairness in the use of limited resources: It depends upon the patients interests to return home if adequate health care support is available. If a society encourages home care, it also has an ethical responsibility to look after both the patient and the family care givers. The Ethics of pain control Patients with advanced cancer have a right to demand and it is our duty to administer sufficient analgesic to control their cancer pain. The ethics of the prolonging treatment Nurses have a professional and moral responsibility to make sure that a patients refusal of lifesustaining measures is not due to the feelings of guilt or depression. But preservation of life at all costs is not necessary when the patient finds it unacceptable to spend money on the treatment. The decision will depend upon the following: I. Patients willingness to stop the treatment. II. When treatments are the source of more suffering than benefit. III. Stopping treatment is ethically no different from never starting it.

Clinical presentation On Self instructional module on care of cancer patients