Case study

End of life nursing care

Renal cell carcinoma

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.

Anatomy

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.

Tell us a story about a time when you had an extraordinary connection with a patient/client

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