7.6 Oncology, Palliative & End-of-Life Care

Oncology, Palliative and End-of-Life Care

Neoplastic conditions are one of the CARICOM Blueprint's categories of common health problems. Examples in its age-group tables include leukaemia, brain tumours, Wilms' tumour, breast, uterine and ovarian cancer, cancers of the prostate, stomach and lung, and benign prostatic hyperplasia. Prostate, breast, cervical and colorectal cancers are major causes of death in the Caribbean, and prostate cancer rates are especially high among men of African descent. The RN's roles run from prevention and screening, through treatment side-effects, to palliative and end-of-life care.

Prevention, Early Detection and Screening

• Warning signs to teach (the classic "CAUTION" list):
  • a change in bowel or bladder habit;
  • a sore that does not heal;
  • unusual bleeding or discharge;
  • a thickening or lump;
  • indigestion or difficulty swallowing;
  • an obvious change in a wart or mole; and
  • a nagging cough or hoarseness.
• Primary prevention: no tobacco, a healthy weight and diet, physical activity, limited alcohol, HPV and hepatitis B vaccination, and sun protection.
• Screening (secondary prevention), following the national programme:
  • cervical: Pap smear or visual inspection with acetic acid, and increasingly HPV testing, which WHO recommends as the primary test;
  • breast: breast self-awareness, clinical breast examination and mammography;
  • colorectal: faecal occult blood or FIT testing, or colonoscopy; and
  • prostate: an informed, shared decision about PSA and digital rectal examination, starting earlier for men of African descent.

Treatment Modalities and Nursing Care

Chemotherapy

Chemotherapy kills rapidly dividing cells, so it also harms bone marrow, the gut lining and hair follicles. Blood counts usually reach their lowest point, the nadir, about 7–14 days after a dose.

Safe handling: chemotherapy is a high-alert, hazardous medicine. Use chemotherapy-rated gloves and gowns, dispose of cytotoxic waste in the designated container, and wear gloves when handling the client's body fluids during the period set by policy. Staff who are pregnant should follow occupational health advice.

Radiotherapy

• External beam: wash the treated skin gently with lukewarm water and pat it dry. Do not wash off the treatment markings. Avoid heat, sun, tight clothing and products not approved by the radiotherapy team. Expect fatigue.
• Sealed internal sources (brachytherapy): apply time, distance and shielding. Use a private room and limit visiting time; staff who are pregnant and young children should not enter. If an implant is dislodged, never pick it up by hand. Use long-handled forceps to place it in the lead container and notify the radiation safety officer.

Oncological Emergencies

• Spinal cord compression: new back pain followed by leg weakness or bladder or bowel changes. Urgent imaging and steroids are needed.
• Superior vena cava syndrome: facial and arm swelling, distended neck veins and dyspnoea.
• Hypercalcaemia: confusion, constipation, polyuria and dehydration.
• Tumour lysis syndrome: high potassium, phosphate and uric acid with low calcium after treatment starts. Hydration and monitoring are key.

Palliative Care

WHO describes palliative care as an approach that improves the quality of life of patients and their families facing life-threatening illness. It works through the prevention and relief of suffering by early identification, assessment and treatment of pain and other physical, psychosocial and spiritual problems. Palliative care can start at diagnosis, alongside curative treatment. It is not only for the last days of life.

Pain Control

WHO's principles for cancer pain are "by the mouth, by the clock, for the individual, with attention to detail". Give regular doses around the clock, plus breakthrough doses for extra pain. The classic WHO analgesic ladder steps up from:

1. non-opioids (paracetamol, NSAIDs) ± adjuvants;
2. weak opioids for mild to moderate pain; then
3. strong opioids such as morphine for moderate to severe pain.

Opioid side-effects:

• Constipation does not lessen with time, so give a laxative routinely with regular opioids.
• Nausea and drowsiness usually settle within a few days.
• Clinically important respiratory depression is uncommon when doses are titrated to pain.

Fear of addiction should not lead to undertreatment.

Other Symptoms

• Dyspnoea: sit the client upright, use a fan, and give low-dose opioids as prescribed.
• Anorexia: offer small, appealing meals, and accept reduced intake near the end of life.
• Constipation: prevent it.
• Delirium: look for reversible causes.
• Mouth care: keep the mouth moist and clean.
• Psychological and spiritual support: include the family.

Care at the End of Life

Signs that death is approaching:

• increasing sleepiness and less interest in food and fluids;
• cool, mottled extremities;
• falling urine output;
• Cheyne-Stokes or irregular breathing, sometimes with noisy upper-airway secretions; and
• reduced responsiveness.

Hearing is thought to persist, so keep speaking to the client and encourage the family to do so too. Reposition the client for secretions and give prescribed anticholinergics. Do not deep-suction a dying client routinely.

Grief often shows in the Kübler-Ross stages of denial, anger, bargaining, depression and acceptance. These stages are not linear, and people move back and forth. Anticipatory grief starts before death. Respect cultural and religious practices. Many Jamaican families hold a Nine Night gathering after a death, and families may want prayer, singing or particular rituals at the bedside.

Advance care planning: document the client's wishes and the agreed resuscitation decision clearly, following institutional policy. Communicate them at every handover.

Care after death (last offices):

• Death is pronounced by an authorised practitioner.
• Give the family privacy and time.
• Follow religious and cultural wishes.
• Label the body according to policy.
• Close the eyes and support the jaw.
• Remove tubes and lines unless the death is to be referred to the coroner (sudden, unexpected or unexplained deaths). In that case, leave all devices in place.
• Document the care and the time of death.
• Look after yourself and your colleagues too: debriefing helps prevent compassion fatigue (Section 12.1).