The Cowboy: Hospice Care and the Terminal Esophageal Cancer Patient

1. The Cowboy: Hospice Care and the Terminal Esophageal Cancer Patient Kay M. Sackett, EdD, RN December 16, 2010

2. Selected Pertinent Patient Information JS 56 year old Male Born 08/29/1945 Unmarried, long term girlfriend Two living siblings Retired Navy Enlisted Retired Barber Cowboy Artist   History of PTSD   Alcohol abuse   Chronic Smoker 3-4 packs/day   Diagnosed Esophageal Cancer Stage 4B June 2009   Home hospice provided by long-term girlfriend Moravian

3. Current History Chronic nonproductive cough History of hypertension currently on no medications Dyspnea on exertion and shortness of breath when resting required O2 @ 2-3 L prn via nasal prongs Chronic anemia with Hgb 5 si units (Normal male 8.7-11.2) Hematocrit .32 (Normal 0.42 - 0.52) equals low RBCs volume and hypoxemia Chronic fatigue PTSD with periods of confusion   Generalized weakness   Chemotherapy and radiation treatments begun but aborted per patient request after week 6 due to radiation burns of the throat, esophageal strictures Current pain medications include: Oxycotin 30 mg poq 8 hours; Fentanyl Patch 75mg. changed q 2 days; Tylenol 650mg pox 2 q 4hours prn; Dulcolax Suppository 1 daily prn, Imodium 5 ml. poprn

4. Today’s Foci JS C/O chronic intractable pain in the neck, esophagus and shoulders JS desire to use nonpharmacological pain relief in the form of Healing Touch

5. Pathophysiology Stage IV esophageal cancer is divided into stage IVA and stage IVB, depending on where the cancer has spread. Stage IVA: Cancer has spread to nearby or distant lymph nodes. Stage IVB: Cancer has spread to distant lymph nodes and/or organs in other parts of the body. http://www.cancer.gov/cancertopics/pdq/treatment/esophageal/Patient/page2 - Keypoint13

6. Nursing Physical Assessment Pupil equal and responsive to light (PERLA) Respirations 16-18 B/P 126/78 Pulse 80 at rest 96 on exertion Positive bowel sounds X4 prn incontinence GU has a foley draining cloudy increasingly yellow urine Skin dry and intact Alert and oriented X3 with some periods of confusion Alternating black tarry stools and constipation Requires assistance with ambulation due to positive risk of fall Peripheral pulses wrist +2 ankles +1 Pain assessment = check for quality, duration, severity, location, aggravating and/or alleviating factor Intense, constant 0-10 scale is always between a 9-10 in the neck and shoulders Chemotherapy and radiation therapy discontinued by patient. Hospice care with palliative measures related to pain control and nutrition Pharmacological Pain Management includes: Oxycotin 30 mg po q 8 hours; Fentanyl Patch 75mg. changed q 2 days; Tylenol 650mg po x 2 q 4hours prn; Dulcolax Suppository 1 daily prn, Imodium 5 ml. po prn O2 @ 2-3 L prn via nasal prongs

7. Nursing Diagnoses http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/ Chronic pain arising from actual or potential tissue damage or defined in terms of such damage   NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months. Energy Field Disturbance…………. NANDA Definition: A disturbance of the flow of energy surrounding a person’s being which results in disharmony of the body, mind and/or spirit Care Giver Role Strain………….. NANDA Definition The focus of this care plan is on the supportive care rendered by family, significant others, or caregivers responsible for meeting the physical and/or emotional needs of the patient

8. Sample Patient Goal and Nursing Outcomes Classification Patient Goal Nursing Outcomes Classifications (NOC) Patient verbalizes acceptable level of pain relief and ability to engage in desired activities Pain control   Quality of life   Family coping http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=41

9. Nursing Interventions Nursing Interventions Classifications (NIC) http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index Pain management Heat and cold Simple Massage Healing Touch (Not NIC) closest relevant are Therapeutic Touch and Energy Management http://www.rncasemanager.com/articles/NursingInterventionsClassificationLabelsDefinitions.pdf

10. Nursing Care Plan Chronic Painhttp://www1.us.elsevierhealth.com/Evolve/?site=/MERLIN/Gulanick/ Ongoing Assessment Assess pain characteristics: • Quality (e.g., sharp, burning) • Assess the patient’s perception of the effectiveness of methods used for pain relief in the past.--Patients with chronic pain have a long history of using many pharmacological and nonpharmacological methods to control their pain. • Evaluate gender, cultural, societal, and religious factors that may influence the patient’s pain

11. Nursing Care Plan Chronic Pain Therapeutic Interventions Acknowledge and convey acceptance of the patient’s pain experience. The patient may have had negative experiences in the past with attitudes of health care providers toward the patient’s pain experience. Conveying acceptance of the patient’s pain promotes a more cooperative nurse-patient relationship. Provide the patient and family with information about chronic pain and options available for pain management. Lack of knowledge about the characteristics of chronic pain and pain management strategies can add to the burden of pain in the patient’s life. Assist the patient in making decisions about selecting a particular pain management strategy. Guidance and support from the nurse can increase the patient’s willingness to choose new interventions to promote pain relief. The patient may begin to feel confident about the effectiveness of these interventions.

12. Nursing Care Plan Chronic Pain Education/Continuity of Care Teach the patient and family about using nonpharmacological pain management strategies: Cold and/or heat applications Massage of the painful area Healing Touch Knowledge about how to implement nonpharmacological pain management strategies can help the patient and family gain maximum benefit from these interventions.

13. Determining the Level of Evidence Based Practice Search Strategy

14. Articles for EBP Assignment Cassileth, B.R. & Vickers, A.J. (2005). High Prevalence of Complimentary and Alternative Medicine Use Among Cancer Patients: Implications for Research and Clinical Care. Journal of Clinical Oncology, Vol 23, No 12, pp 2590-2592. Freese, J. (2003). Healing Touch in the Hospice Environment. Healing Touch Newsletter. Volume 03, Number 4, p. 6-7. Langford, R.M. (2006). Pain management today-what have we learned? Clinical Rheumatology 25 (Suppl 1): S2-S8. O’Mathuna, D.P. (2000). Evidence-Based Practice and Reviews of Therapeutic Touch. Journal of Nursing Scholarship, 32:3, 279-285. Post-White, J., Kinney, M.E., Savik, K., GauBerntsen,J., Wilcox, C. & Lerner, I. (2003). Therapeutic Massage and Healing Touch Improve Symptoms in Cancer. Integrative Cancer Therapies 2(4), pp. 332-344. Van den Beuken-van Everdingen, M.H.J., de Rijke, J.M., Kessels, A.G., Schouten, H.C., van Kleef, M & Patijn, J. (2007). Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology. Advance Access published March 12 2007. Wardell, D.W. & Weymouth, K.F. (2004). Review of Studies of Healing Touch. Journal of Nursing Scholarship. 36:2, 147-154.

15. EBP Assignment • Review articles provided about chronic pain in cancer patients and use of selected complimentary and alternative therapies including Healing Touch for nonpharmacological treatment • In which tier of the evidence based hierarchy do you place the article? • In which tier of the search strategy hierarchy do you place the article?

16. Evaluation NEEDS WORK!!!!! Patient moved from home hospice care provided by girlfriend to hospice facility Nursing staff and physician assessed need for change in pain/medication management (NIC categories) due to increased intractable and unreliaved pain, change in mentation, and   Change in pain/medication protocol to provide better pain control Continuation of Healing Touch per patient request

17. Recommendations Continue chronic pain medication management to keep patient as comfortable as possible Continue non pharmacologic Healing Touch at the hospice facility per patient, girlfriend and family request

18. The Cowboy: A Self Portrait

19. Debriefing • Aim of the presentation • The aim of this presentation was to • Assessment of whether this was accomplished • Thank you for the opportunity to interview for a faculty position at Virginia Commonwealth University.

20. Questions and Answers