Competence in Cancer Care: What the Nurse Needs to Know End of Life Care and Survivorship Amy Ford BSN, RN, OCN © 2013 Nurse Oncology Education Program.

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Slide 2 Competence in Cancer Care: What the Nurse Needs to Know End of Life Care and Survivorship Amy Ford BSN, RN, OCN 2013 Nurse Oncology Education Program. All rights reserved. Do not reproduce, redistribute, post online, or otherwise reuse this work without permission. Slide 3 End of Life Care Slide 4 Grief and bereavement process Family support Education Complex symptom management Reimbursement issues Community resources Hospice End of Life Care Slide 5 Living wills Do not resuscitate (DNR) / Allow a natural death Power of attorney Durable power of attorney Advance Directives Slide 6 Advance directive stating the types of care or medical interventions the patient prefers or wishes to avoid Living Wills Itano & Taoka, 2005 Slide 7 States that the patient refuses any potentially life prolonging interventions CPR Chest compressions Intubation Defibrillation Do Not Resuscitate (DNR) Itano & Taoka, 2005 Slide 8 Patient gives power to transact business on his/her behalf when he/she cannot do so because of time or distance (although physically able). Power of Attorney Itano & Taoka, 2005 Slide 9 Patient gives power to transact business on his/her behalf when patient is no longer able. Durable Power of Attorney Itano & Taoka, 2005 Slide 10 Palliative - care that is intended to relieve but not cure Hospice - care designed to provide for the needs of the client and family as they deal with terminal illness Metastasis Disease is progressing with treatment Disease recurs after remission Poor prognosis Palliative vs. Hospice Care Itano & Taoka, 2005 Slide 11 Community based program In-patient program In-patient hospice team/palliative care team Freestanding hospice Types of Hospice Care Itano & Taoka, 2005 Slide 12 Grief - a persons response to and experience of loss Feeling emotionally numb Feeling unable to believe the loss occurred Mourning along with depression A feeling of acceptance Bereavement - the state of having suffered a loss and the experiences that follow the death of a loved one Grief and Bereavement www.cancer.gov Slide 13 National Hospice and Palliative Care Organization www.nhpco.org www.nhpco.org Hospice Net www.hospicenet.orgwww.hospicenet.org Get Palliative Care www.getpalliativecare.orgwww.getpalliativecare.org Hospice and Palliative Nurses Association www.hpna.org www.hpna.org Community Resources Slide 14 Medicare Hospice Benefit of 1983 ensures all beneficiaries may access end of life care More than 80% of hospice patients are Medicare beneficiaries Reimbursement www.texashospice.com Slide 15 Interdisciplinary Team Pharmacist Therapist Spiritual Counselor Social Worker Nurse Hospice Physician Patient Slide 16 Current standard of practice Is goal directed Indicates consistency in actions, interventions and the patients plan of care Ensures accountability and patient confidentiality Meets current legal and regulatory requirements Interdisciplinary Team www.legacycare.com Slide 17 Assessment of Pain Intensity NoMildModerate SevereVeryWorst painpainpainpainseverepossible painpain Verbal Pain Intensity Scale Visual Analog Scale 010 Numeric Pain Intensity Scale No Moderate Worst pain pain possible pain 0123456789 10 No pain Worst possible pain www.painedu.org Faces Pain Scale Slide 18 Culturally Specific Tools Pain scale used in Dhahran, Saudi Arabia Slide 19 Pharmacologic Nonopioid Analgesics (acetaminophen, aspirin, ibuprofen, naproxen Opioid Analgesics (morphine, meperidine, fentanyl, oxycodone, hydromorphone) Pain is whatever the patient says it is, and exists wherever he or she says it does. (McCaffery, 1968) Comfort Measures for Pain Rosdahl, 2007 Slide 20 Initial therapy for mild pain Decrease inflammatory mediators (NSAIDs) NSAIDs + opioids = dose-sparing effect Effective for bone pain and inflammation Use NSAIDs with caution in the elderly Acetaminophen as an alternative Nonopioids: NSAIDs www.cancer.org Slide 21 Used to manage moderate to severe pain Produce analgesia by binding to specific receptors within and outside the CNS Have no ceiling effect If confusion occurs, decrease dose If confusion continues, change opioids Must monitor and treat side effects Opioid Analgesics www.cancer.org Slide 22 Antidepressants Anticonvulsants Antianxiety Adjuvants www.cancer.org Slide 23 WHO 3-Step Approach 3 Moderate to Severe NONOPIOID Adjuvant NONOPIOID Adjuvant OPIOID Nonopioid Adjuvant OPIOID Nonopioid Adjuvant OPIOID Nonopioid Adjuvant 2 Mild To Moderate 1 Mild Hydromorphone Morphine Fentanyl Meperidine Oxycodone Buprenorphine Codeine Hydrocodone Propoxyphene Codeine Hydrocodone Propoxyphene AcetaminophenNSAIDsIndomethicin Adjuvants: Tricyclic Antidepressants Anticonvulsants Antihistamines Corticosteroids Increasing Pain Freedom from Cancer Pain www.who.int/cancer/palliative/painladder/en/ Slide 24 Nonpharmacologic Clean and smooth sheets Soft and supportive pillows Soothing environment Massage Position change and movement Relaxation exercises Comfort Measures for Pain Wild Iris Medical Education, 2012 Slide 25 Frowning, grimacing, fearful facial expressions Fidgeting Striking out Eating or sleeping poorly Sighing, groaning, crying Breathing heavily Change in gait or behavior Nonspecific Pain Signs and Symptoms Slide 26 Who perceives pain as worse? Fear of addiction Fear of uncontrolled pain Fear of side effects Family Caregiver Managing Pain Slide 27 Survivorship Slide 28 Seasons of Survivorship A person who has been diagnosed with cancer, from point of diagnosis through remainder of life AcuteTransitionalExtendedPermanent Miller, 2009 Slide 29 Survivorship Statistics Estimated 12 million cancer survivors in the U.S. 1 in every 25 Americans is a cancer survivor CDC, 2011 Howlader, et al., 2011 Slide 30 Cancer Survivors Over 12 million now; will double by 2050 Over 20 million globally 3 out of 4 families will have at least 1 family member diagnosed with cancer 66% of adults diagnosed can expect to be alive in 5 years 61% of survivors are > 65 years of age Ries et al,2008. Slide 31 Survivorship Issues Physical Concerns Practical Concerns Emotional Concerns Slide 32 Physical Concerns Secondary malignancies Cardiomyopathy Pneumonitis Opportunistic infections Pain Thyroid insufficiency Sexuality Sterility Pregnancy post-therapy www.cancer.net/survivorship/late-effects Slide 33 Fatigue Fatigue Pre-existing conditions Cancer Cytokine activity Tumor by products Symptoms Related to cancer Related to treatment Nutrition Muscle mass loss Sleep disruption Demands of dealing with cancer Slide 34 Emotional Concerns Fear of recurrence Self esteem Spirituality Less contact with medical team Coping Cognitive function Chemo brain Chemo fog Slide 35 Cognitive Function Chemo Brain - impairment during and after cancer diagnosis and treatment Impacts patients, families, QOL No approved treatments at this time Non-specific Symptomatic Treatment Measure Education and counseling Psychostimulants Exercise, yoga, acupuncture www.cancer.org Slide 36 Practical Concerns Discrimination Work related issues Financial concerns/Debt Insurance Legal Issues www.cancer.net/survivorship/late-effects Slide 37 Cancer Rehabilitation Improve physical strength Become more independent, less reliant on caregivers Adjust to actual, perceived, and potential losses due to cancer and cancer treatment Reduce sleep problems Lower the number of hospitalizations www.cancer.net/survivorship/rehabilitation Slide 38 Surveillance National Comprehensive Cancer Network (NCCN) Practice Guidelines http://www.nccn.org/professionals/physician_gls/f_guideli nes.asp http://www.nccn.org/professionals/physician_gls/f_guideli nes.asp American Society of Clinical Oncology (ASCO) Clinical Practice Guidelines http://www.asco.org/ASCOv2/Practice+%26+Guidelines/G uidelines/Clinical+Practice+Guidelines Slide 39 ACS Nutrition and Physical Activity Guidelines for Cancer Survivors Achieve and maintain a healthy weight Be physically active Resume exercise as soon as possible 150 minutes each week Strength training 2 days per week Eat a healthy diet Fruits Vegetables Whole grains Rock et al., 2012 Slide 40 End of Life Care Legal Issues Hospice Care Grief and Bereavement Interdisciplinary Team Palliative Care Slide 41 Survivorship Seasons of Survivors Statistics Issues (physical concerns, emotional concerns, cognitive function, practical concerns) Cancer Rehabilitation Surveillance American Cancer Society Nutrition and Physical Activity Guidelines Slide 42 Additional Resources www.cancer.net www.cancer.net www.cancer.org www.cancer.org www.getpalliativecare.org www.getpalliativecare.org www.hospicenet.org www.hospicenet.org www.hpna.org www.hpna.org www.nccn.org www.nccn.org www.nhpco.org www.nhpco.org www.painedu.org www.painedu.org www.who.org www.who.org