Mary Camilleri who suffers from locally advanced pancreatic cancer, which has metastasised to her liver, was recently informed of her poor prognosis. Literature defines prognosis by the level of tumor metastasis, TNM staging, lymph node involvement, neural, vascular and peri-pancreatic invasion, tumor differentiation and size, and involvement of resection margins (Perini M., et al. 2008). Hence at this stage, due to the advanced disease the patient is unable to undergo surgical resection which is the only potential curative treatment. El Kamar F., Grossbard L., Kozuch P., (2003), illustrate that approximately 80% of the patients with metastases or local extension present with unresectable disease. Sadly the solely goal of therapy is to provide palliation care that is comfort and support to maintain quality of life (Thomson B., Banting S., Gibbs P., 2005). The World Health Organization (2002) defines palliative care as;” An approach that improves the quality of life of the patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of and other problems, physical, psychosocial and spiritual.” As soon as cure seems no longer an option, palliative care should be delivered to the patient. Palliative care is not intended to impede or delay death but to regard it as a normal process of life. The concept of palliative care as described above is to humanize and personalize care to the dying for the remaining days. Nurses are able to play a crucial role in palliative care due to their close and sustained contact with the patients. Pancreatic cancer, like any other cancer has an impact on the physical, psychological, social and spiritual well-being of both the individual and their family. Therefore a good palliative nurse needs to put forward qualities of compassion, empathy, being able to provide comfort, combined knowledge, good communication and listening skills and a confidence to ‘ be with’ those in need during this devastating illness (Mirando S., 2006). Becker (2000) further highlights the core skills needed in the holistic role of a palliative nurse which includes; communication skills, psychosocial skills, team skills, physical care skills, life closure skills and intrapersonal skills. According to Yan S. M., & Myers R. P., (2007), 90% of patients in advanced pancreatic cancer stage will suffer from pain; therefore, for Mary Camilleri one of the cornerstones of management in palliative care is to provide relief, from pain and disease-related symptoms. Brown E. Chambers J., Eggeling C., (2007) emphasize that pain is known to adversely affect the patient’s quality of life. Without doubt an effective care plan needs to be established to assess and manage any issue that is ultimately affecting the patient and the family. Thereby a plan of care based on a holistic framework needs to prioritize problems, identify needs, values and goals, consider the cultural and spiritual diversity and facilitate the provision of psychological care (Mirando S., 2006; Pearce C., & Lugton J., 1999). The psychological aspect is also a principle in palliative care that should be addressed through; the patient and family education in relation to the condition and discussions about sensitive issues such as hopes of survival and fears associated with death. Beaver K., et al. (2000) provides plenty of evidence that a caring approach embraced with psychological, psychosocial and spiritual support is highly effective and is valued by the patients and their families. But unfortunately, there is high evidence that patients with advanced cancer still do not meet their physical and emotional needs (Mirando S., 2006). The relationship between the nurse and the patient needs to foster hope, autonomy and choice. The nurse should encourage Mary to take part in decision-making, as it will help her to feel in control of her illness. Although continuously challenged by the progressive illness maintaining hope, is one way to help patients achieve and maintain quality of life (Rideout E., & Montemuro R. N., 1986). Supportive care is a substantial part of palliative care, where the nurse needs to support the patient and the family to cope throughout the disease, treatment, death and bereavement (Becker R., 2009). Without doubt many issues will arise within the family such as role and responsibility changes, adjustments in work, emotional strain and more. At this point, all the members of the multidisciplinary team should be present to sustain Mary and her family. The environment is also an important factor that is taken into account during palliative care. The surroundings must allow and retain a sense of dignity and control. The nurse together with the patient should plan and decide the preferred place of care where a comfortable environment can be created (Mirando S., 2006). In conclusion the aim of palliative care for Mary Camilleri is to achieve a ‘ good death’ where comfort and support is provided till the end of life. In regards to the nurses, Thompson G., et al. (2006) points out the importance of being with the patient and the family during this time rather than ‘ doing’ alongside the patient.
How would you assess and manage her current uncontrolled symptoms?
” Nurses need to be able to understand and manage different types of pain in a coordinated manner to ease discomfort at the end of life” (Hughes L., 2012). Often as the disease progresses, the pain also increases in its severity (Berry D. et al., 2010). In the case of Mary Camilleri, she is currently complaining of an increasing abdominal pain and nausea. The nurse together with other healthcare professionals should continuously assess the patient and family reaction to the illness and plan interventions that address the problem but in the meantime support their values and choices. Discussing the abdominal pain with Mary is important to acquire the information necessary to control the symptom. According to Ramage- Morin P. (2008), pain assessment models are helpful since describing pain can be difficult for the patient. Pain description aids the clinicians to make the appropriate treatment (Urch C. 2011). The SOCRATES pain questionnaire is recommended in palliative patients to assess their level of pain. It consists of points that describe; the site of pain, which in this case is the abdominal region, the onset of pain, the character of pain, any radiating pain, associated symptoms, the time or pattern of pain in relation to any activities, any exacerbations or anything that relieves the symptoms and the severity rating. The pain scores used help to gauge and quantify the pain in the form of a scale from 0 (no pain) to 10 (severe pain). First attempt to manage pain may not fully affect pain, thus reassessing is important (Simon C., 2008). Continuous reassessment will prevent poor outcomes and it gives the patient the confidence that in itself helps to relieve pain. The etiology of pancreatic cancer is not fully understood, thus, having a great impact on the management. According to the American Cancer Society (2013), abdominal pain is a common sign observed in locally advanced pancreatic cancer. It is described as a dull, constant pain in the epigastric region. The pain radiates to the back and may worsen at night or when lying flat. Obviously pain is felt in that area due to location of the pancreas that extends horizontally into the abdomen behind the stomach. In pancreatic cancer pain may be visceral, somatic or neuropathic in origin (Lebovits A., & Leftkowitz M., 1989). The abdominal pain may be generated from the infiltration of cancer cells into the pancreatic nerves which seems to exacerbate neuropathic pain. As the cancer advances, the damage further extends into neighbouring organs including the celiac plexus, lymph nodes, capsules and vascular structures. The celiac plexus is sympathetic nervous system that transmits visceral information from the upper abdominal organs, away through the celiac plexus synapse to reach the spinal cord (Caraceni A. & Portenoy R., 1996). Invasive cells may enlarge the lymph nodes and stretch the surrounding neural tissue increasing the pain. Another source that seems to trigger pain is the ongoing inflammation process that causes the pancreatic nerves to become increasingly sensitive to the chemicals and mechanical stimuli. This may be due to the; loss of myelian sheath, decreased threshold stimulation, prolonged or enhanced response to the stimulation or an increase of neurotransmitter release at the spinal cord making it more excitable (Chen Wai Tsan T., 2009). Other studies also suggest that abdominal pain seems to arise from the distension or obstruction of ducts that causes an increase in pressure, such as the biliary, gastric or duodenal obstruction or from a resultant pancreatic insufficiency (Evans D. B., Abbruzzese J. L., Willett C. G., 2001). When obstruction occurs an endoscopic stent can be an option in palliation to reduce the pain. These sophisticated techniques offer alternatives for those unfit for surgery (Watanapa P., & Williamson R., 1992). Other problems may result due to the pancreatic function loss or metastasis, for instance ascites and hepatomegaly (Hidalgo M., 2010). Pancreatic pain relief is an ongoing challenge to many health care professionals. As the disease advances, certain treatment becomes increasingly inappropriate and Mirando S., (2006) suggests outweighing the benefits and burdens of giving such treatment. Brescia J. F. (2004) determined that certain treatment decisions were based on the patient’s age, past treatments and the proximity to death. Pain control is based on pharmacological and non-pharmacological measures (Riehl M., 2007). The WHO (2009) has formed a standardized approach for analgesic drug regimens in the form of a ladder. To increase the efficiency of treatment the clinicians need to consider the types of pancreatic pain. This stepwise approach uses non-steroidal anti-inflammatory drugs and opioids. Quigley C., (2005) identified Morphine, Oxycodone or Hydromorphone as the drug of choice for moderate to severe cancer pain. Slowly increasing the dose will help to experience less adverse drug reactions. Assessing the dose, duration of treatment and the overall condition of Mary is essential especially due to her liver metastasis. Take into account associated side effects of opioids such as constipation which can also increase abdominal pain. Adjuvants may be added to the treatment such as; corticosteroids for nerve compression and inflammation, and anticonvulsants for neuropathic pain. If opioids are ineffective a celiac plexus block can be performed. Basically it is the blockage to inhibit pain transmission. This has shown evidence of controlling pain with a reduction of opioid consumption. According to Thomson B. et al. (2005) chemotherapy, radiotherapy and a combination of both may be used to relieve the pain related to infiltration and metastasis. However, patients with locally advanced pancreatic cancer and liver metastasis undergoing such treatment need to be carefully assessed and should have a reasonable performance status. A poor medical condition may interfere with the ability to tolerate chemotherapy and are more susceptible to cytotoxic side effects (Gee C., 2011). Before, 5-Fluorouracil was the chemotherapeutic agent used in metastatic pancreatic cancer patients. Currently, Gemcitabine is a standard nucleoside analogue used in locally advanced and metastatic pancreatic cancer patients. Gemcitabine showed a better systemic activity and is a well tolerated drug with favourable toxicity profile that allowed combination regimens (El Kamar F., et al. 2003). Two studies regarding Gemcitabine in advanced pancreatic cancer demonstrated that considering the poor prognosis of these patients and the limited therapeutic options available, this treatment improved disease palliation (Moore M., 1996). According to Hsue V., et al. (1996), radiotherapy also provides palliative benefits in fact almost 50% of the patients report considerable improvements in pain. Yet, high dose regimens may cause gastrointestinal toxicity and may take several weeks to control pain. Although chemoradiation is associated with a greater toxicity level, it is considered as a great alternative to chemotherapy alone (Polistina F., 2010). In addition to the treatment, other non-pharmacological management can be implemented for instance; relaxation, music, art, prayer, meditation, massage, application of cold or heat and therapeutic exercises (Hameed M., Hameed H, Erdek H., 2011). Mary is also experiencing nausea, which is one of the most discomforting symptoms that result both from the disease itself and from treatment especially chemotherapy (Harris D. G., 2010). Nausea is described as a wave-like sensation in the epigastric area, associated with other symptoms such as pallor, diaphoresis, and tachycardia. Harris D. G. (2010) illustrates that, nausea prevalence ranges from 16% – 70% but increases if chemotherapy is administered. Tumor metastasis, metabolic abnormalities, the stimulation of the vestibular system, stimulation of the cerebral cortex by anxiety, stimulation of the sympathetic nerves in the GI tract, delayed gastric emptying or any obstruction may be the reasons that lead to nausea (Stephenson J. & Davies A., 2006). When a minimum threshold is reached information is transferred to the medulla, which in turn triggers nausea (Ang S. K., Shoemaker L. K., Davis M. P., 2010). Nausea is assessed so that to avoid serious unwanted outcomes that affects the quality of life. Assessment should include physical examination, any concurrent therapy related to pancreatic cancer that may induce nausea such as chemotherapy, and verification of any patterns that indicate the cause of nausea, for instance the timing, precipitating factors, frequency, duration and severity. The measurement of severity can be done through a scale to quantify the symptom (The Hospice of the Florida Sunset, 1998). Take into consideration other factors that may affect or worsen the symptom such as anxiety or depression. According to Rhodes V. A., & McDaniel R. W. (2001) by discussing, questioning and observing, the nurse can holistically assess the patient and increase further compliance. The management relies on identifying the pathophysiology of nausea so that the correct anti-emetic is chosen. The pharmacological management is based on two approaches the empirical and the etiological. The empirical approach recommends the use of antiemetic drugs regardless of the cause of nausea. In locally advanced pancreatic cancer and metastasis, it is not always possible to verify the etiology due to the multiple causes. On the other hand, the etiologic approach is very effective as it involves identifying the contributing factors and avoids over-medication (Glare P. et al., 2004). The different antiemetics include; dopamine antagonists, histamine antagonists, serotonin antagonists, anticholinergic antiemetics and prokinetic antiemetics. Selecting an antiemetic depends on the patient’s status, severity of nausea, the drugs adverse effect and the available route. Adjuvant medications to treat nausea may be added to any step in the WHO (2002) ladder. Pharmacological management can be combined with the non-pharmacological management. Measures such as; using deep breathing, voluntary swallowing technique, oral care after each emesis, applying cool cloth on the forehead or neck and sitting in fresh air. The nurse can advise the patient to eat frequent and small meals using bland food or to avoid lying flat for more than 2 hours after eating (The Hospice of the Florida Sunset, 1998). Over all pancreatic cancer treatment remains a challenge as the mortality rate is approximately equals to the incidence thus showing that treatment is almost still ineffective. In conclusion the nurse is in the best position to intervene while being sensitive to the verbal and non verbal cues of both the patient and the family. The key of nursing role in the management of pancreatic cancer is to provide a holistic approach to deliver a valuable good end-of-life care.