Nursing Management in Cancer

            Learning to make
            a difference!
   Describe the impact of cancer on coping, body image and
   Define & describe key features of hospice palliative care, &
    end-of-life care
   Outline the goals of hospice palliative care & end-of-life care
   Outline role of the nurse in hospice palliative care & end-of-
    life care
   Discuss importance of personal awareness in hospice
    palliative care nursing
   Describe nursing role in communication
   Discuss common issues around end-of-life decision-making
   Complete required readings as listed on homepage,
    specifically chapters 17
   Review list of recommended readings
   An overview of palliative nursing Ferrell &
    Coyle (2003)*
*Please note that the definition of palliative care has been
    revised since this article was published. The article is
    excellent otherwise
   Dying with dignity
  Case Study 1
Mrs. Haider is a 45 year old woman of Arabic descent.
  She has advanced ovarian cancer. Recent test
  results indicate that her cancer is progressing and
  end-of-life issues need to be discussed. Mrs. Haider
  immigrated to Canada 10 years ago with her
  husband and 3 children. Her understanding of
  English is limited. Her husband accompanies her to
  all appointments to translate for her. He often
  answers questions and makes decisions without
  communicating with her. Today Mrs. Haider
  appears withdrawn. She si very quiet and does not
  make eye contact. You are concerned about how
  she is coping.
   How would you approach this situation?
   What issues are important to consider when
    caring for Mrs. Haider?
   What resources could be considered?
     Case Study 2
Mary, 38 y/o. Works as a secretary at a busy law firm. Mary
    was diagnosed with early stage breast cancer and after
    discussion with her surgeon she decides to undergo a
    mastectomy, axillary lymph node dissection, and immediate
    reconstruction. Mary is very athletic and did not want to
    bother with a prosthesis. She thought reconstruction would
    feel more natural and she wanted to appear “normal” to
    anyone who saw her. The reconstruction process will
    require multiple steps.
Following her surgery, Mary finds out that the path report
    indicated 2 out of 5 lymph nodes removed are positive;
    Therefore adjuvant chemo is recommended. This means a
    potential delay in the reconstruction process. Mary is upset
    about losing her hair.
   What are some possible issues facing
   Describe how you would approach Mary
    about these issues?
   What are some possible
   Are there resources in your community that
    might be helpful to Mary?
   Cancer & the Person
How will the person with cancer,
  their family deal with initial
  diagnosis, treatment, &
  short/long term consequences
  to self & to significant others?

Helping the patient/family to
   retain as much control over
   the situation as possible

Knowing and following patients'
   wishes for end-of-life care
Cancer has taken me twice and flung me to a new
space. The first time, I overcame the fear of
cancer. This time, I’m working on the anger of
recurrence. Always a strong person, I feel both
experiences have given me strengths I never have
believed I was capable of. I have a deeper sense
of life and joy. So in spite of the hair loss, the
energy loss, and the protocols, I am becoming
tempered, like steel. My metal is tested, and I am
not found wanting. I’m living on a higher plane
of existence.
                               (Ferrell, 1995).
   "Cancer changes your life, often for the better.
    You learn what's important, you learn to
    prioritize, and you learn not to waste your time.
    You tell people you love them. My friend Gilda
    Radner (who died of ovarian cancer in 1989 at
    age 42) used to say, 'if it wasn't for the downside,
    having cancer would be the best thing and
    everyone would want it.' That's true. If it wasn't
    for the downside."
    August 6, 2001 - Joel Siegel
 Cancer Affects:
All levels of functioning
 Intellectual
 Psychological
 Physical
 Spiritual
 Self-concept
Individual Responses to Cancer
Depend upon:
   The client’s psychological make-up
   The client’s family & social community
   The disease, disabilities & disfigurement it
    may cause
   Preexisting medical conditions that may
    limit treatment options
       Psychosocial Aspects of Cancer
   Cancer is a feared and dreaded
    disease because:
May be present in advanced stages
    with no manifestations
Compliance with vigorous and often
    disfiguring treatments doesn’t
    guarantee a cure
Cancer may recur after many years of
A healthy life-style does not ensure
    escape from the disease
Coping refers to the ability to adapt
  functionally to stressors. Coping is
  not a single act, but a process that
  changes over time.
   Coping styles, or efforts aimed at
    reducing or eliminating stressors,
    vary among individuals and
    The Ability to Cope Is Influenced By:
   Past experiences
   Culture
   The context of the stress
   The nature of the illness (stage, rx. Etc.)
   Developmental stage
   Social supports
   Spirituality
   Personality dimensions
      Meaning of the illness to the person
      Tendency to be anxious
      Optimism
      Locus of control
Certain factors may hinder coping:
Denial                 Avoidance
Helplessness           Powerlessness
Hopelessness           Depression
Guilt                  Isolation
Wishful thinking       Erosion of autonomy
Anger                  Blaming others
Have you experienced situations
where you wished you could have
intervened more positively to help
persons with cancer?
Identify a few?
Responsibilities of the Nurse in Cancer Care
   Support the idea that cancer is a chronic illness
   Assess own level of knowledge relative to the
   Make use of current research findings and practices in care of
    clients with cancer
   Identify clients at high risk for cancer
   Participate in primary and secondary prevention
   Assess nursing care needs of client with cancer
   Assess learning needs, desires and capabilities
   Assess social supports of client and family
   Plan and implement appropriate interventions in collaboration
    with the multidisciplinary team
   Evaluate goals and outcome and modify plan of care as
               See Smeltzer and Bare (2007) chart 16-1 p. 324
Nursing Interventions
It is important that nursing interventions
are designed to help individuals cope with
the experience of illness & suffering, and if
necessary to find meaning in such
experiences. Helping the sick to maintain
hope & avoid helplessness is a major
responsibility for the nurse (Rustoen &
Hanestad, p. 19, 1998).
               How to Facilitate Hope
   Encourage belief in oneself & ability (affirm the individual’s
   Encourage emotional expression
   Help recall positive memories, times of joy and fulfillment
   Help maintain meaningful relationships with others
   Support spiritual beliefs & values
   Be honest & clear in delivery of “info”
   Focus on the present – day by day – rather then an uncertain
   Help find images symbols or rituals that foster hope
   Help conserve or enhance available energy, control pain
Hospice-Palliative Care
What is hospice-palliative care?
Key Features of Hospice Palliative
   “Whole person” care
   Combines science, presence, openness,
    compassion, mindful attention to detail,
    and teamwork
   The patient & family are the unit of care
   Goal is quality of life & relief of suffering
   Includes care of the dying and bereavement
     Who is the hospice palliative care
   The patient facing a life-threatening illness
    (regardless of the type of illness or the stage,
    ranging from new diagnosis to terminal
    prognosis) in need of specialized care to
    promote physical, psychosocial, and spiritual
      What is end-of-life care?
   The care that patients and their families receive
    when patients are near death or dying.

   This can include palliative care, hospice care,
    and/or supportive care, although not all patients
    who receive supportive or palliative care are
    actually receiving end-of-life care (Kinzbrunner
Premises of End-of-Life Care
   The dying are not people for whom “nothing can
    be done”

   Everything will be done to

•   Promote comfort
•   Promote dignity
•   Involve & support significant others
Goals of Hospice Palliative Care
   The patient and family’s wishes are
   The patient and family feel a sense of
    control over the situation
   The patient is comfortable
     Hospice Palliative Care Nursing
   Provision of effective pain and symptom
   Addressing the psychosocial and physical needs
    of the patient and family
   Incorporating cultural values and attitudes into
    the plan of care
   Supporting those who are experiencing loss and
     Hospice Palliative Care Nursing
   Promoting ethical and legal decision-making
   Advocating for personal wishes and preferences
   Using therapeutic communication skills
   Facilitating collaborative practice
The Importance of Personal
   Personal experiences with loss and grief

   Attitudes and fears of death and vulnerability

   What would I want and need if I were seriously
    ill or dying

   Who’s needs am I meeting?
     Where is hospice palliative care
   Hospice palliative care can be initiated through
    a number of referral systems and is provided in
    both community and institutional settings
   Active listening
   The four C’s
       Collaboration
       Credibility
       Compassion
       Coordination
   Gathering and processing information
   Critiquing and evaluating data for veracity
   Filtering and communicating knowledge in
    an accurate, concise, and timely manner
   Updating other team members with new
   Engaging in dialogue to solve problems
    and participate in decision making
   Avoiding jargon or vague terminology
   Adjusting communication style for roles,
    personalities, and circumstances
   Being assertive and confronting conflict
    directly and respectfully
   Consideration of and caring for others
   Advocacy
   Conveying respect in verbal and non-verbal
   Fostering positive emotions in others
   Effective leadership
   Encouraging input from others
   Mentoring
   Acknowledging contributions of others
   Facilitating participation of others
End-of-Life Decision Making
       Common Issues
                                     Designating care for
                                     Proxy decision-making
                                     Taking care of
                                      “unfinished business”
   Which treatments to accept
    or decline and when
   Arranging for allocation of
    worldly possessions
   Possible organ donation
    Common Symptoms
   Pain              Anorexia/cachexia
   Nausea and         Depression
    vomiting           Fever
   Fatigue            Urinary
   Constipation
                       Skin breakdown
   Candidiasis
                      Confusion/delirium/
   Dyspnea            restlessness
Signs & Symptoms of Approaching
   Increasing physical      Noisy respirations
    and emotional             “terminal bubbling”
    withdrawal               Incontinence of urine
   Reduced food and          & stool
    fluid intake             Changes in skin
   Confusion/agitation       temperature and
   Change in breathing       colour
     Nursing Interventions
   Providing comfort
   Ensuring safety
   Addressing physical and emotional needs
   Explaining what is happening to the patient and
   Supporting & sustaining patient/family
   Helping the patient/family to retain as much
    control over the situation as possible
   Knowing and following patients' wishes for
    end-of-life care

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