Introduction
The importance of palliative care strategies emanates from the fact that interpretation of events is much more important than the reality itself (Corey, & Corey, 2007). Thus, it is important to help cancer patients interpret positively, whatever they are going through. There is a need for strategies that lead to eliminating some of the fears associated with palliative care, such as breathlessness-which is commonly encountered with those in palliative care (Maher and Laureen, 2005).
According to Wang et al. (2008), cancer patients may not enjoy life to the full, and they may fail in their usual activities as a result of severe problems arising from the symptoms exhibited by the disease. Many of the studies related to this subject have concentrated on the need to solve problems and issues surrounding the symptoms, rather than the actual disease.
In a way, these studies are weak, because some extrapolate to extremes, the need to take more care of the cancer patients’ symptoms, than the cure for it. In addition, some of these research studies lack much evidence in regard to the issues under investigation: for instance, regarding the issue of patterns of symptom clustering (examples include, Chen and Tseng, 2006; cited in Wang et al., 2008).
The issue of clustering in this respect is limited in ideology and acceptability (probably) because it is incompletely discussed. Widely informed and further research is needed to confirm some aspects and claims by some of these previous researches. Some of these studies also are cumbered with weaknesses. Wang et al. (2008) miss to get support from their investigation, as to whether unique patterns of symptom clustering is evident in lung cancer patients, and they have resulted to positing that their study results indicate a possibility that such clustering is the same across different cancer diagnoses (Wang et al., 2008).
Various strategies for helping patients with cancer are important, as it has been posited that the disease may record increased mortality rates in the future (Central Cancer Registry Center in Korea, 2001; cited in Eui-Geum, 2004). Regarding what issues to blame for the physical and psychological, as well as the social problems in lung cancer patients, the disease’s natural progression and the treatment-related side effects have been pinpointed (Cooley, Short and , Moriarty, 2002; Cooley, 2002; cited in Eui-Geum, 2004). Events, beliefs and feelings are connected according to a theory known as A-B-C (irrational thinking theory) (Corey, & Corey, 2007).
Palliative care strategy is the concern given to patients who are suffering from life-threatening diseases such as cancer, heart disease, neurologic conditions among others. The aim of this is not to halt the condition but rather to alleviate the severity of the disease in order to improve the quality of life for the patient.
The concern is towards the patient’s holistic welfare, which includes social, emotional, spiritual and physical needs. Considering the patients are ailing from a terminal disease, they are taken through a process that helps them take death as a natural process. This would help them live their life fully, and have a positive outlook in life towards improving their quality of life. More modern techniques such as NASM (nurse-assisted symptom management) and ATSM (automated telephone symptom management) have been tried out for symptoms management, but in research (Sikorskii et al., 2007).
These were applied to cancer patients who were undergoing chemotherapy and they were found to be effective. However, it must not be rejected that these systems perform only well in some aspects as compared to the traditional mechanisms of taking care of the patients. Palliative care also seeks to offer health education to the family of the patient so that they can understand the patient’s progress. Thus, the studies concentrating on singular aspects (and investigating singular aspects of palliative care strategies), may be deemed as partial.
Palliative care education helps the family in caring for the patient from an informed perspective of the disease and how it progresses. This provides a good platform for the family to also get counseling since they are also dealing with a sense of loss as their loved one is ailing from a terminal illness.
This paper presents a case study of Clare, a 65-year-old woman suffering from lung cancer, which is an incurable condition. Her general practitioner referred her to a Palliative care center. She suffers from breathlessness, cough and fatigue and gets distressed by the inability to ‘catch her breath’. She sometimes suffers from insomnia at night and often feels sleepy during the day. She says that she lacks the strategies of managing her symptoms and views her illness as a challenge since it affects what she does. She feels that she is lacking control of her life.
Clare lives with her husband, Andrew, in their home. They have two grown children who are married and live interstate. She feels that personal relationships are very meaningful right now and she misses her children though she is in constant communication with them through phone. She is stunned at the number of people who have come to visit her in their home, unexpectedly.
Her husband retired two years ago and helps with the house chores, shopping and cooking for the two of them. In this way he feels that he is doing something to help but would like to be more helpful. The Community palliative care centre has health workers trained to assist the patients and their family get holistic care. This will help Clare and Andrew understand what they can do to improve the quality of life. Assessment will be carried out and guidance on how to manage the symptoms.
Case Management strategies
Lung cancer is a leading course of death in the cancer related diseases. There being no screening recommended, many tumours are recognised in later stages of the disease. At this stage the tumours have spread to other places or within a region and this can cause physical and psychological distress, thus the need for palliative care. Common symptoms of lung cancer patients include fatigue, pain, anorexia and insomnia. Patients suffering from pain, dyspnoea and anorexia are classified as advanced cases. Depression and fatigue are symptoms found in patients in different stages.
Clare’s diagnosis shows symptoms of fatigue, cough and breathlessness. Since she feels inadequate in the management of her symptoms, the nurse offering palliative care could advice accordingly after assessment. Clinical assessment is done for haemoglobin screening to detect anaemia in relation to fatigue as the patient is advised not to ignore the symptom.
The patient is examined whether they look tired or relaxed. Fatigue can also be assessed using Brief fatigue Inventory (BFI), which is a scale ranging from 0 to 10 meaning no fatigue and severe fatigue respectively (see Ji-hyun, 2008). BFI also examines on what the symptom of fatigue interferes with. This could be the daily activities that patient carries out, exercise among others.
Difficulty in breathing is assessed through checking respiratory rate which in a normal case would be 16-20 breaths per minute. Assess the schedules of sleep of the patient, whether Clare sleeps during the same time every night, sleeps during the day or wakes up feeling refreshed. Pain assessment is carried out since fatigue would be caused by it. In assessing Clare’s psychological condition, the nurse would seek to know what issues are stressing her.
Is she having worries about money, the disease and treatment regimen? Is she worried about her roles and the ability to accomplish them? Is she concerned about her personal relationship with friends and family? This is with the aim of knowing what is causing stress to the patient so that the patient and family are advised on how to address these issues.
Lung cancer can be assessed using the functional assessment of lung therapy- Lung cancer (FACT-L) and Lung cancer symptom scale (LCSS). FACT-L measures the physical and functional well being of the patient (see Kristine, et al., 2009). LCSS measures quality of life with visual analogue scale that check on six major symptoms and their effects on the quality of life, distress and function.
Breathlessness or dyspnoea is considered more a subjective symptom and thus no specific measure of assessment can be used. This is evaluated from the complete history given by the patient as it depends more on the patient’s level of activity. Important symptoms are examined and a cardiopulmonary assessment done to assess dyspnoea. Thorough check on this helps to determine whether the condition is acute or reversible.
Symptom management of dyspnoea is given through oxygen therapy, pharmacological therapy or palliative/supportive care. Cough can be a result of direct or indirect effect by tumours. Pain should also be assessed and the self report of the patient be considered as the primary source of assessment. Assessing the patient’s condition is an initial step in planning their treatment regimen. Thus when the nurse takes all this information from Clare, it enables understanding of the stage of the disease. This further guide on how administering medication and providing holistic support to the patient will be planned.
Physical support
Physical support may be necessary to cancer patients, because there may be physical symptoms they may not be easy to palliate and these may be linked with depression. Thus solving some physical problems may also be linked to solving some psychological problems (distress in particular) (Radbruch, et al., 2003; Hotopf, et al., 2002; cited in Mari et al., 2004). Physical problems experienced with advanced cancer patients include fatigue and poor mobility (Curtis, et al., 1991; Coyle., et al., 1990; cited in Mari et al., 2004).
Non pharmacological therapy includes exercise for the patient to aid breathing. There are factors that need to be analyzed, namely the underlying disease of the patient, the quality of life, as well as the clinical presentation in the application of pharmacological interventions to aid breathing for palliatives (Maher and Laureen, 2005). Guidelines for managing patients with cancer counsel that they should be involved in physical exercise. It is necessary for patients to be taught to regulate breathing and relaxation techniques, among others, as well as making sure that the caretakers understand the issues concerned.
The frequency and duration should be done depending on the patient’s needs. Clare can be encouraged to do physical exercise in which Andrew can participate or assist Clare. Energy conservation is another way of helping the patient where they are to plan for their day depending on the energy resource and progress. This enables them to participate in activities that they value and achieve their goals. Through this Clare can begin to feel that she is in control which she says is lacking.
She can also be able to do what she enjoys and thus improving the quality of her life. Since Clare is suffering from lack of sleep at night and feels sleepy during the daytime, sleep hygiene practices will be a good recommendation. Through this she can have regular time schedules for sleeping and avoid stimulating activities like taking coffee in the night or sleeping for long hours in the daytime.
The patient’s diet is also a factor to consider in the improvement of the quality of the life of the patient. Patients ailing from lung cancer should have fat free diets (see Sons, 2006). Increasing the intake of fruits and vegetables is highly recommended. Taking a lot of foods and drinks containing minerals, vitamins, proteins, and carbohydrates is very essential. Lack of sufficient nutrients can cause the patient to get weak and lack the ability to fight the infection.
Providing a balanced diet for Clare during this time would also be vital for her health. In the endeavour to be more helpful to Clare, Andrew could ensure that he buys these foods that provide balanced diet. Nutrition guidelines are also provided for cancer patients. This can be an important step for Andrew and Clare to take as they would learn the nutritional requirements which would help to fight infections and rebuild tissues.
Clare would be encouraged to do progressive muscle relaxation using guided techniques. Exercise and respiratory muscle training can strengthen her muscles. Massage can also promote her posture and relaxation. The nurse can take Clare through breathing techniques like pursed lips and diaphragmatic breathing. Using a mask or administering gas through mask can help in dealing with the breathing difficulty. Patients also use complementary alternative methods (CAM). Positioning and reducing energy expenditure can help Clare in minimising dyspnoea.
Pharmacological therapies are also done to the patient in palliative care. These include erythropoiesis stimulating therapy for correcting anaemia with haemoglobin that is less than 10g/dL.
Patients who have gone through this therapy have been reported to experience reduced fatigue. It’s however been noted that patients treated through erythropoiesis stimulating therapy with a dose of 13g/dL haemoglobin can be at risk of life threatening cardiovascular problem as compared to a dose of 11.6 g/dL. Psycho stimulants like methylphenidate or dextroamphetamine can also be administered. Steroids can also be used to reduce fatigue but caution should be observed in order to avoid myopathy or inspection which can occur due to prolonged use. Antidepressants are also administered to patients suffering from depression.
They should however not be administered if a patient is fatigued and not depressed. The nurse would educate Clare on how to manage pain and fatigue as that is essential to successful management. Opioids such as morphine which has been the most predominant are administered to patients with dyspnoea. Addiction should however be cautioned to the patient. Oxygen therapy given to patients with hypoxemia has been known to reduce dyspnoea.
Psychological support
Porter, et al., (2008) have focused on the self-efficacy (one’s confidence) to personal adjustment to cancer. They feature the case of cancer control. A relatively low rank is indicated for patients and their caregivers, as far as self-efficacy to manage pain and symptoms is concerned, for the investigated category of patients.
They proclaim the possibility for the need to providing good patient self-efficacy, as well as that of their care givers. Included in this study were depressive symptoms as well as fatigue. The study is successful but lack evidence for application for wide range or types of cancers. The researchers identify for the need to carry further research to include investigations for each person’s self-efficacy as well as application of multiple measures for investigating self-efficacy, meaning that they are not conclusive.
Palliative care offers psychological care for the patient in order to improve the quality of life for the patient and family. This helps the patient deal with anxiety, depression, fear and distress. Going through a life threatening illness subjects the patients to depression and the nurse focuses on this need as well as the others. Cognitive behavioural therapy is carried out where the seriousness of the disease and its consequences are examined. The patient is encouraged to be open to the palliative care nurse and to the support group for better understanding of their progress.
It would be expected that every patient coping with cancer would experience feelings of helplessness and feels like they would loose control (Akechi et al., 1998; Uchitomi, et al., 2003; cited in Porter et al., 2008).
The study by Porter et al (2008) estimates that either there were some factors not included and which led to higher levels of self-efficacy and symptoms of distress that are at lower levels or that higher level of perceived self-efficacy resulted from lower symptoms and distress levels. Behaviour cognitive therapy aims at solving the problems of dysfunctional emotions, behaviours by having a systematic procedure to achieve a certain goal. This deals with anxiety, moods, and insomnia and fears that the patient is experiencing.
The use of cognitive behavioural therapy has been found to reduce the use medication on patients suffering from insomnia and also improving the patient’s condition. Kristi et al., (2006) examine distress in a sample of patients and seek to examine their rates and predictors in a cancer clinic which is multidisciplinary in nature. The authors find that higher levels of distress were related to such problems like cognitive, and physical functioning, as well as family relationships among other things.
Distress is not predicted by family problems and anxiety. Such distress may interfere with ability to coping with cancer and may be of physical, emotional, social and psychological nature (National Comprehensive Cancer Network, 2003; Holand, 2003; cited in Kristi et al., 2006). Kristi et al., case is limited as far as ethnic diversity is concerned. There are no data incorporated for study decliners. They apply broad rather than specific categories for the data regarding the treatment type and participants (2006).
Psychological therapy can be given to a patient through a support group where they come together and learn from each other by sharing about themselves. Stress reduction techniques can also help the patient; these include activities such as yoga, visualisation, and meditation. Participating in activities that bring pleasure to the patient such as artistic activities, reading, poetry, gardening, helping other, and community work among others help to reduce distress.
Proper planning of activities the patient wishes to involve in help reduce distress as through this they feel they are in control of life. Clare can be guided on a support group in the centre in which she can attend and Andrew can join in to learn more about the condition and progress. Stewart et al., (2010) point that it would help to have an empathic responses for patients of cancer so as to ease negative emotions.
The authors examine the way patients who have advanced cancer will express emotions to (non-physician clinicians) NPCs (see also Fogarty et al., 1999; Mager, et al., 2002) but they indicate that there is no knowledge if NPCs respond empathically or not. The NPCs fail to address the emotional aspects (Stewart et al., 2010). Chochinov et al., 2005 have found that dignity surveys are important in helping patients psychologically to deal with illnesses.
Social support
Patients are impacted as far as their relationships with loved ones are concerned (Breitbart, Rosenfeld and Passik, 1996; Wilson et al., 2004; Meier, et al., 1998; Van et al., 1991; cited in Chochinov, 2005). Patients may be more concerned or disturbed by the psycho-social and existential issues than the issues of physical symptoms manifesting physically, and the pain itself (Field and Cassel, 1997; cited in Chochinov, 2005).
Patients may experience poor quality of life as a result of undermined dignity (and other issues) in end-of-life care (Chochinov et al., 2002; Chochinov, 2002; Chochinov, Hack, and Hassard., 2002; Chochinov, 2004; cited in Chochinov, 2005). Palliative strategies enable the family to understand the patient’s progress through health education. This helps to improve the quality of life for the patient ailing form the life threatening disease. This is part of the package in the treatment regimen for the patient where they get support from the family. This is considering that the patient goes through distress which comes as a result of fear from loss.
The patient fears that they are losing their job prestige, income, role in the family, social position and control of life among others. The patient can feel distressed that they are a burden to the family and are isolated from the community as they are considered weak due their ailment. Due to this, the patient requires support systems to encourage her improve the quality of life. Family becomes a great support as they are the closest interaction the patient is having in their day to day life.
Clare’s husband who has been very supportive and desires to be of greater help. The nurse can provide more information on Clare’s physical and psychological needs. Clare considers personal relationships very meaningful and misses her children though they are in constant phone contact with them. Andrew could be helpful in bringing them together thus providing a great support for Clare. Sometimes sick people are handled as weak and not able to function normally. They are isolated from the day to day activities that they took part in before the illness, sometimes in conversations, or responsibilities they handled.
It may be true that they would not be in a position to do everything as before, but this kind of isolation can cause distress. It would be therefore necessary to give emotional support and listen to the patients as they go through the treatment. Through this they come to accept their condition and feel appreciated in the course of the treatment.
Clare would need to be open to talk about these changes that happen to her during the illness and Andrew could listen to her and provide emotional support. Clare having indicated that she doesn’t have many strategies to help her manage her symptoms is an opportunity for Andrew to be more helpful. He can attend the treatment sessions with her and through the information they get; Andrew would help Clare in doing the practical part while at home.
Patients suffering from lung cancer should have fat free diets. Increasing the intake of fruits and vegetables is highly recommended. Taking a lot of foods and drinks containing minerals, vitamins, proteins, and carbohydrates is very essential. Lack of sufficient nutrients can cause the patient to get weak and lack the ability to fight the infection.
Providing a balanced diet for Clare during this time would also be vital for her health. In the endeavor to be more helpful to Clare, Andrew could ensure that he buys these foods that provide balanced diet. Nutrition guidelines are also provided for cancer patients. This can be an important step for Andrew and Clare to take as they would learn the nutritional requirements which would help to fight infections and rebuild tissues.
Community support can be found in support groups for cancer patients. Palliative care centers have this support groups where other cancer patients share their experiences and can be of encouragement to Clare. Having indicated that she is finding a challenge in the impact the illness is having on her, hearing other people’s experiences can help her identify with the symptoms she is experiencing.
This however may be an environment which takes the patient out of the ‘normal’ social setting and further makes them feel isolated to those who are ‘like them’. Andrew and Clare attending social events together would also be a way of getting community support. Clare would also be encouraged to be open about her disease so as to keep her friends and family at ease. By this she can talk about her progress with those concerned and this can aid in her getting support from them.
Spiritual support
Spiritual peace is one of the aspects deemed by patients at their end-of –life care facets. Studies show that spirituality and religion has helped patients dealing with terminal illnesses. The families of patients with life threatening diseases have found great solace in this too. It is however an area that is not addressed or less attended to by many physicians. Since this area of the patient’s life is not commonly addressed in the hospitals the family can be best placed to encourage the patient in this.
The patient also needs personal motivation to seek spiritual help as it would be impossible to impose on them the importance of this. Since the essence of Palliative care is to provide holistic care for the family and the patient, spiritual well being is an aspect not to be ignored. Of essence is to know how and when to bring up the topic of spirituality to the patient. In many cases this concern is raised at the later stages of the illness when the patient is in the advanced stages. It can be a source of peace, comfort and contentment to the patient and family.
Clare can be given spiritual support either in the group or at home with the family. Since Andrew wants to be more helpful and could be aware of Clare’s religious background, he would be of help in praying with her or reading scriptures together with her. This would help Clare in having hope, reduce distress and worry, and give her strength in dealing with the illness.
He can be in a position to know the appropriate time of bringing up the topic. An environment of love and support encourages the patient to accept her condition and live life normally in the process of taking death as a natural process. In this view, Andrew as the husband has the responsibility of providing unconditional love to Clare.
Conclusion
Lung cancer exhibits conditions that cause the patient to have difficulty in breathing, feel fatigued and cough a lot. As it progresses, the disease exhibits severe conditions which may lead to death of the patient; it’s thus a terminal illness. The treatment depends on the cell type of the cancer, how far it spreads and how the patient is progressing. This causes the patient to feel distressed, lose control in life and can affect their eating habits and social life. Palliative care services help the patient and family cope with the treatment procedure from the time it’s diagnosed, through treatment and even to the advanced stages of the disease.
The family in this case has responsibility in the process of treatment procedure given to the patient. The patient’s effort to focus on other issues and not just the sickness can help them to live normally. Since the aim of palliative care is to give emotional, social, spiritual and physical support to the patient and family, health education is vital. It’s important for the family to go through counseling as they deal with a member of the family having terminal illness.
Palliative care seeks to cater for the health of the patient holistically, and not just the pharmacological management alone. The family can be taken through bereavement even after the ailment has advanced and the patient has passed on. Clare having been referred to a palliative care centre would be examined and her symptoms assessed so that proper planning and implementation of treatment procedure can be given. Health education is provided to her and her husband, counseling is also provided for the family. This ensures that Clare’s needs are met taking into consideration social, psychological, spiritual areas.
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