Seeing the forest for the trees

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Seeing the forest for the trees
Seeing the forest for the trees

I have been privileged to serve as a medical oncology nurse for the past 23 years. I always considered it a calling, and caring for those with life-threatening illnesses has been fulfilling and challenging. Oncology nurses are charged with constant changes in therapy. New oral chemotherapy medications and other therapeutics lead to new challenges and new patient successes every day. We have to be on our toes all the time. I tell newly hired nurses, "This is a thinking nurse's job!"

In practice, I focus on maintaining quality of care, enhancing clinical standards, and supporting progressive research, but I had become so involved in the "big picture" of patient care that I had forgotten the importance of reviewing the smaller details. A recent patient, Mr. E, caused me to reassess my big-picture focus and evolve my approach to more holistic patient care.

Mr. E is a vibrant 90-year-old man whose infectious laughter can often be heard resonating throughout the chemo room. He is a special patient; that rare person with a magnetic personality that draws people to his side. Nine months ago, he was given a diagnosis of stage IV colorectal cancer. Mr. E's performance status was excellent with few comorbities, so we proceeded with chemotherapy. After cycle 3, however, Mr. E was showing signs of severe fatigue and lethargy, and the hearty laughter that once flowed through the room with each visit had diminished. As you might guess, he was not a complainer, but in a quiet moment he revealed his greatest concern to me. His great granddaughter was to be married and, with his fatigue and shortness of breath, he knew he would not be able to attend her wedding. I resolved to find a resolution for Mr. E's symptoms so he could make the trip.

SEARCHING FOR A CAUSE

I evaluated any and all causes that could have had this profound effect on him. I reviewed all of his bloodwork including CBC, BMP, and tumor markers. CBC revealed decreased hemoglobin and hematocrit, which met the indication for ESA therapy, and I hoped the growth factors would improve Mr. E's fatigue. To complete the search for answers, I ordered a PET scan to rule out metastasis.

As the test results came back, including an unremarkable PET scan showing stable disease, Mr. E's symptoms remained relatively unchanged. Even with the ESA therapy, his hemoglobin levels did not improve. Once again, I dug in my heels and searched for answers. I reevaluated every step of his care from A to Z; despite this, Mr. E was still fatigued with shortness of breath. Or, to put it in his words, "just plain tuckered out." What was I missing?

As I reviewed all his test results with the nursing staff, one of my new trainees asked, "How about his iron stores?" The light went on! Mr. E's iron studies were not current, and we had initiated ESA therapy. Could this be functional iron deficiency anemia? Mr. E's iron stores were adequate at the initiation of therapy, but did adding ESA therapy exhaust his iron stores?

A quick lab draw confirmed the diagnosis. The patient was iron deficient. I had been so focused on evaluating for a clinical diagnosis related to the patient's cancer that I overlooked his supportive care therapy.

Mr. E received a 1-g cycle of iron, IV push, over two visits (days 1 and 8). Follow-up evaluation on day 30 revealed an increase of 2 g/dL in the patient's hemoglobin level and improved iron stores. More importantly, Mr E's fatigue and shortness of breath were significantly improved. Not only was he returning to his old self, but his hope was restored. The trip was booked for the wedding, and we had a happy patient.

When Mr. E returned to the clinic after the wedding, he threw his arms around my neck and thanked me for the iron boost saying, "Not only did I attend the wedding, but I danced with a lovely bride! Thank you."

As oncology nurses, we are exposed to patients from all walks of life, different ages, different aspirations, different hopes and dreams, and different motivators. The common fabric among them all is their cancer diagnosis. While we tend to focus first and foremost on the chemotherapy, the important lesson here is that supportive care should not be ignored. We have the power and an obligation to our patients to provide the best and most comprehensive care possible. In this case, traditional evaluation of the more common causes of fatigue (eg, cancer progression) failed to inform a cause. Only when considering other causes did we find the solution. Mr. E continues to come to the clinic. His laugh has returned, and he serves as a reminder to me to view each patient individually and to look at both the forest and the trees. ONA


Robin Wachsman is vice president of clinical services at The West Clinic in Memphis, Tennessee.

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