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Lorna’s story
77 y. o. retired female
Lived with her husband and sister in a shared rental unit
2 supportive daughters and 2 granddaughters
Goes to small local chapel nearby
History of Hypertension, Obesity, Anxiety, Cholecystectomy (surgical removal of the gallbladder)
Lorna’s story cont.
Allergic to Hydrochlorothiazide (diuretic drug)
Presented to GP with intermittent left flank pain, abdominal pain and increased fatigue and weakness
Diagnosed with advanced renal cell carcinoma in early 2011
L nephrectomy the same year
Lorna’s story con.
Reoccurrence of renal disease in April 2014
First admission to CHCB for symptom management of increasing right hip pain and functional decline - not able to cope at home
X-ray showed bilateral joint degenerative changes with subchondral sclerosis and degenerative changes to lumbar spine
Ongoing complex, severe pain difficult to manage
Increasingly depressed, anxious and tearful
Anaemia requiring transfusion
MRI in August 2014 – cauda equina compression (T1-L2)
Drowsy, urine retention (IDC inserted), faecal incontinence, severe lower limbs weakness (secondary to the tumour infiltration)
Palliative radiotherapy to spine
Story cont. Readmitted to CHCB for ongoing symptom
management
Decreased appetite/Minimal oral intake
Lost at least 20 kg since diagnosis
Focus on pain & symptom management
Non-essential medications ceased
CSCI via syringe driver
Psychological and spiritual support to patient and family
Terminal care
LCP
Metastatic renal cell carcinoma
RCC or adenocarcinoma – the most common type of kidney cancer – starts in the lining of small proximal tubules in the kidney
Stage 4 – tumour has invaded other organs
The 10th most frequently seen cancer in Australia typically discovered when the person is 50-70
Average survival = 5 years
Risk factors: cigarette smoking, hypertension, obesity and genetics
Most common metastases – lungs, liver and long bones
Early warning signs – abdominal discomfort, fatigue, weight loss.
Later – haematuria, flank pain, anaemia, palpable abdominal mass
Proximal Convoluted Tubule
circulates water and reabsorbs glucose, amino acids, metabolites and electrolytes from the filtrate into nearby capillaries. This is where the RCC in most cases starts from.
Cauda Equina syndrome (CES)
CES affects a bundle of nerve roots called the cauda equina (Latin for horse's tail) where something is compressing on the spinal nerve roots such as a tumour.
These nerve roots send and receive messages to and from your legs, feet, and pelvic organs. Damage to these may result in severe low back pain, faecal incontinence, urinary retention and severe lower limb weakness.
Cauda equina syndrome
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Medication
Variable dose medication delivered subcut via Syringe Driver every 24 hrs - Oxycodone Injection (40mg) for pain
Regular prescriptions – Dexamethasone 2mg PO/SC in the Morning – Indication: Cauda equina compression Olanzapine 2.5mg PO/Sublingual/SC Twice Daily – Indication: agitation
As Required prescriptions – Metoclopramide10 to 20mg q4 hours PRN, PO/SC up to 80 mg per 24 hours for nausea/vomiting Midazolam Injection 2.5 to 5mg q1hour PRN, up to 2 doses per 4 hours, SC – indication: agitation
Medication as required con.
Glycopyrrolate 0.2mg/1mL Injection SC 0.2 to 0.4mg q 4 hours PRN for respiratory secretions
Pregabalin 75mg capsule, 75 mg q 12 hours PRN, 2nd line for severe pain not responding to oxycodone
Haloperidol 0.5 to 1mg q 1 hour PRN, PO/SC up to 2 doses per 6 hours. For agitation/delirium: minimum dosage interval = 1 hr. For nausea or vomiting: minimum dosage interval = 6 hrs
Oxycodone Injection 5 to 7.5mg q 1 hour, PRN, SC
End Of Life Nursing CareSymptoms and Interventions
Skin integrity is maintained – assessment (itch, sweating, pressure areas) - cleansing, repositioning, use of special aids (Braden score 10)
Urinary problems – IDC/use of pads
Bowel problems – constipation/diarrhoea
Administration of medications – CSCI/ SC butterfly
Personal hygiene – skin care, eye care, wash
Psychological well being – verbal and non-verbal communication, listening, information and explanation, use of touch, spiritual/cultural needs
Symptoms and Interventions
Nausea/Vomiting – treatment depends on the area of stimulation (chemoreceptor trigger zone/CTZ and the vomiting centre) – often difficult to control
Agitation/distress/anxiety – consider spiritual issues, listening, support, open discussion with patient and family, psychotropic drugs –benzodiazepines, antidepressants
Respiratory secretions – ‘death rattle’ – positioning to allow postural drainage, drugs – anticholinergics (hyoscine hydrobromide, glycopyrrolate)
Pain
“Pain is whatever the person experiencing it says it is, existing whenever he says it does.”
Verbal if Pt conscious
Non-verbal cues
Positional change
PRN / BT analgesia for incident pain/prior movement
Pain
Psychological and spiritual elements of pain –anxiety, sadness, anger, frustration
Pain of loss
Loss of role
Loss of independence
Loss of future
Nurse being at the bedside, fully present giving a ‘dose’ of herself – respectful verbal and non-verbal communication, caring touch
LCP issues
One –way road to death?
Backdoor form of euthanasia?
OR
Improves care at the end of life?
Results in more “good deaths”?
OR
Travel to Liverpool for treatment (as one husband misunderstood)
Review the use of LCP in palliative settings – poor implementation and possible falsification
Compassionate care
Patient satisfaction is closely related to the quality of kindness, caring, compassion and trust
Magical moments of healing occur when a profound connection is made
The patients emotional and psychological wellbeing impacts more powerfully on physical health outcomes than most of the medicines we use
Work intensity, demands, lack of recourses –disorganised, pressured reactive pattern of patient care that focuses on clinical tasks rather than caring for the whole person
Very often the human touch is missing
Hug – form off communication because it can say things you don’t have words for.
Four major shifts to re-humanise healthcare (Youngson, 2012)
Reductionist focus on
Pathology
Detached care
Focus on sickness,
defects and problems
Health professional
directing care
Focus on whole person
Empathetic, compassionate care
Focus on wellbeing, strengths and resilience
Health professional serving the patient’s goals
Think about....recommendations
“We don’t have time to care”- the first step in finding time to care is simply to stop/slow down. Give your patient complete attention – in moments of close connection, the time stands still – patients feel you spent much more time with them.
Tell patients you have time – “Is there anything else I can do for you before I leave? I have time.”
Small acts of kindness
Stop treating patient impersonally, detached – “MND in room 6” or ‘darling, honey, sweetie’
Bad moods are contagious
A ‘good’ nurse doesn’t mind being moved from one job to another???
Effective healthcare system needs to inspire and support compassionate caring and healing relationships –difficult to achieve in the stressed healthcare institutions we mostly work in.
References:
Institute of Medicine (IOM). (2008). Cancer care for the whole patient: Meeting psychosocial health needs, Washington, DC: The National Academies Press
MacLoad, R., Vella-Brincat, J. & Macleod, A. D. (2012). The palliative care handbook: Guidelines for clinical management and symptom control (6th
ed.). Wellington, New Zealand:Crucial Colour
NHS Improving Quality. (2013). Liverpool care pathway for the dying patient. Retrieved from http://www.endoflifecare.nhs.uk/care-pathway/step-care-in-the-last-days-of-life/liverpool-care-pathway.aspx
Sachdeva, K., Makhoul, I., Javeed, M., & Curti. Renal cell carcinoma. Retrieved from www.emedicine,medscape.com/article/38054
Watson, J., & Woodward, T. K. (2010). Jean Watson’s theory of human caring. In M. I. Parker, & M. C. Smith (Eds.), Nursing theories & nursing practice (3rd ed., pp. 351-369). Philadelphia, PA: F. A. Davis Company
Youngson, R. (2012). Time to care: How to love your patients and your job. Raglan, New Zealand: Rebelheart Publishers
Gardner, A., Gardner, E. & Morley, T. (2011). Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J 20:690-697
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