1. INTRODUCTION:

I am an Assistant Professor working in nursing college since 4 1/2 years. As a teacher my role involves supervise the students in the clinical area, to take part in clinical teaching, to maintain clinical capability via regular clinical practice and to guide the students in pain and symptom management, patient advocacy and education of the patient and family with the goal to achieve the best quality of life for patients and their families.

Nurses are “ideal providers” of palliative care, according to a report on the future of nursing by a committee of nurses and other health experts that was released in 2010 by the Institute of Medicine (IOM)⁽¹⁾. As a key member of the health care team, my cited client a 40 year old female, who is a known case of ovarian cancer made me to realize that complex nature of physical and psycho social problems faced by these patients demand good medical and nursing attention, but such a system of care alone not adequate.

2. Case Summary.

A 40 year old female, she is a known case Ovarian Cancer stage IV admitted for 6^th cycle of chemotherapy. My cited client, a homemaker was diagnosed to have ovarian cancer in 2012. She was diagnosed at a local hospital and referred here for further treatment. Here she underwent surgical staging and debulking surgery 2 ½ years back followed by concurrent chemotherapy. Now she got admitted for her 6^th cycle of chemotherapy and also reported the following complaints.

a) Pain/ discomfort in abdomen or pelvis

b) Weakness and giddiness since 1 week

c) History of weight loss and

d) History of loss of appetite

PAST HISTORY:

Nothing significant

FAMILY HISTORY:

My client reported that her husband is hemiplegic since 2 years and also her sister has malignancy of spine with metastasis to kidney and now she is on radiation therapy.

ON EXAMINATION:

Thin built and poorly nourished

Dehydrated and pallor

Icterus, cyanosis, clubbing, lymphadenopathy and pitting pedal edema were absent

Pulse: 80/min, regular and of low volume.

BP: 100/70 mm of Hg, Random blood sugar: 113 mg/dl

§ Chest: Bilateral equal air entry with normal vesicular breath sounds.

§ Abdomen: Soft, non tender, no organomegaly, and normal bowel sounds.

§ Other systemic examination was normal.

Investigation done Reason why the investigation was done

Complete Blood Picture: to assess general condition and infection.

Renal Function Test: to determine obstruction of urine flow and to identify extent of metastasis to bladder and kidneys

Liver Function Test: to identify extent of metastasis to liver

USG Abdomen and Pelvis: to look for changes in the ovaries and other organs caused by cancer.

Biochemistry CA-125: is a tumor marker or biomarker provides information about the biological state of the ovarian cancer

3. Treatment and other Management Plans

· Pain/ discomfort – she was on tab Dolo 650 mg SOS. Provided comfortable position to the patient and taught Physical (massaging, hot pack) and behavioral interventions(redirecting thinking, patient education, psychological support, support groups, religious counseling)

· Hydration - on alternate Ringers Lactate and Normal Saline along with Inj Multivitamin and advised her to increase the fluid intake.

· Monitoring – 4 Hourly Vitals and urine output was monitored.

· Nausea and vomiting- on Ing Metoclorpramide 10 mg b.d, Tab Pantaprazole 40 mg o.d before food and Tab Ranitidine 150 mg b.d

· Sepsis – on antibiotics Inj Meropenem 1gm iv 8^th hourly and Inj Clindamycin 600mg iv 8^th hourly

· Constipation – provided soap water enema and Syp. Cremafin h.s. Also advised her to increase the fluid intake and to include fiber rich foods like cereals, Green leafy vegetables and fruits in her diet.

· Exercise – taught patient about various active and passive exercises and advised her to do it regularly.

4. The outcome expected/anticipated?

The patient was symptomatically better; her pain/discomfort has reduced with tab dolo and non pharmacological measures. Her hydration status was improved with the evidence of increase in skin turgor. Her nausea and vomiting was comedown and her bowel habit has become almost regular. Her overall condition was improved. On request from the patient and family she got discharged on 4^th day with the instruction to review after 2 months with USG abdomen and pelvis and CA-125. Thus the expected result was achieved to a possible extent.

5. Multidisciplinary approach of Patient:

Urologist, nephrologist, physiotherapist, dietician, psychologist and social worker were consulted on various aspects of client care. Cumulative efforts of this interdisciplinary team helped to provide active holistic care of patient and also to clear the doubts of the patient and family.

6. Contributions of Multidisciplinary Approach:

Urologist and nephrologist evaluated thoroughly and excluded any further intervention. Physiotherapist taught the patient various active and passive exercises to overcome any complications that develop due to immobility. Dietician prescribed diet plan for the client to overcome her constipation. Psychologist provided counselling to patient and also to family members and helped them to ease the stress and social worker helped her to find out self help groups and to improve the coping.

7. Palliative care Principles and Practice:

The most challenging part my care was my inexperience and inadequacy in consoling the client and family members and also to make them to understand the reality. She was psychological disturbed and uncertain. Palliative Care, "Actually there is something we can do!” People with chronic illness often experience both periods of stability and periods of decline over the course of an illness. They may have a variety of treatments, surgeries and hospitalizations over months and years. A time may come for some when they may either say to themselves or hear from a health care professional, "there is nothing else we can do." This is a belief that is often rooted in a focus on one’s physical body and a belief that if health care cannot offer a procedure or treatment to cure an illness or condition, that there are no care options and "there is nothing else we can do ⁽²⁾."

Physical care:

Pain control was achieved with non-opioids. Nausea and vomiting was resolved with antiemetics. Constipation was managed with enema and laxatives. Her diet was improved, hydration status was restored.

The psychosocial issues:

My cited client has high psychological disturbance and uncertain. Her husband also was bed bound due to hemiplegia since 2 years and she has got 2 kids, who are doing their schooling. Psychological counseling and Advanced Practice Nursing (APN) interventions which incorporate physical, psychological and care coordination’s are very important in my client for good quality psychosocial care ⁽³⁾.

Spiritual Issues:

Even though my client experienced her health to be seriously threatened, she felt hope, will and courage. Her condition made a comprehensive impact on her life. However hope and spirituality were important resources of comfort and meaning ⁽⁴⁾.

Majority derive strength from their religious beliefs and use these beliefs- Karma, god’s will, fate- to understand situations over which they have no control.

Communication Issues of the Patient and the Family:

The family was quite educated. They were always quite well informed and had accepted about the problems and treatment options and outcomes. So there were no major communication issues among the members of the family. Ovarian cancer affects sexual functioning, but health care professionals’ knowledge about this is inadequate, as is their communication with patients about sexual issues. Health care professionals need training to help them communicate more comfortably about sexual issues. Detailed discussion may be unnecessary -just a few reassuring words may be enough to relieve some of the fears⁽⁵⁾.

8. Ethical Issues:

My client was constantly refusing to undergo further treatment after relapse. But the family had belief in alternative medicines. Towards the end of life the health condition is very fragile. A crisis situation or death itself can happen at any time. Drugs used or procedures done at that time, which has potential for adverse effects may be blamed for death. This can lead to avoidance of such drugs and procedures for fear of the foreseeable adverse effects and potential for being blamed ⁽⁶⁾.

While applying the ethical principles one should employ good communication skill at all levels. Essentially it is working together with patient and family taking into consideration their religious and cultural background. Ideologies and system of care that require dichotomous thinking and black-and-white choices serve the patients and families very poorly.

9. CONCLUSION:

Early involvement of pain and palliative care team for any cancer patient will help to alleviate physical and other symptoms ^(7,
8). We need to improve at recognizing the psycho-social and spiritual needs of the family and active involvement of the psycho-Oncology team.

My client left a thought in my mind that we should have systems of care that allow for people die in peace, to die the way they want to, and to be able to engage in activities that bring peace to them: prayer, meditation, listening to music, art, journaling, sacred rituals and relationship with others. Our systems of care should be interdisciplinary, with physicians, nurses, social workers, chaplain, and other spiritual care providers all working together to provide spiritual and holistic care for our patients.

10. REFERENCES:

1. Advocates call on nurses to take leading role in palliative care. Available at http://www.rwjf.org/en/about-rwjf/newsroom/newsroom- content/2012/09/advocates-call-on-nurses-to-take-leading-role-in-palliative-care.html. Accessed on 24^th December 2014

2. Palliative care. Available at http://sarcomahelp.org/articles/palliative-care.html. Accessed on 24^th December 2014

3. Cynthia K line O’Sullivan, Kathryn H. Bowles, Sangchoon Jeon, E lizabeth E rcolano and Ruth McCor kle. Psychologi cal Distress during Ovarian Cancer Treatment: Improving Quality y by Examining Patient Problems and Advanced Practice Nursing Inter vent ions. Nursing Research and Practice. 2011 (2011): 1-4.

4. Lene Seibaek,Lise Hounsgaard, and Niels Christian Hvidt. Secular, Spiritual, and Religious Existential Concerns of Women with Ovarian Cancer during Final Diagnostics and Start of Treatment. Evidence-Based Complementary and Alternative Medicine. 2013 (2013): 1-4.

5. Maxine L Stead, Julia M Brown, Lesley Fallowfield, and Peter Selby. Communication about sexual problems and sexual concerns in ovarian cancer a qualitative study. West J Med. Jan 2002; 176(1): 18–9.

6. Barnard D et al 2000. Crossing Over- Narratives of Palliative care: Oxford University Press. Pp 11

7. Hui D, E lsayem A, De La Cruz M, et al. 2010. Availability and integration of palliative care at U S cancer centers. JAMA 303:1054–61.

8. Ferris FD, Burery E, Cherny N, et al. 2009. Palliative cancer care a decade later: accomplishments, the need, next steps—from the American Society of Clinical Oncology. J. Clin. Oncol. 27:3052–58.

Received on 07.03.2015 Modified on 05.05.2015

Asian J. Nur. Edu. and Research 5(3): July- Sept.2015; Page 446-448

DOI: 10.5958/2349-2996.2015.00090.7