In this patient’s case, a decision needed to be made regarding treatment in conjunction with the patient’s and family’s wishes. In addition to a very unpleasant odor, fungating tumors are often associated with pain, itching, and bleeding. This patient’s tumor was growing rapidly and, if left untreated, would have caused further morbidity after extensive spread with necrosis and other fungating symptoms.
Medical decision and ethics Although elderly cancer patients often do not receive the standard of care in cancer treatment, no clinical data support the common assumption that elderly pat-ients cannot tolerate radiation therapy.2 This patient had no comorbid conditions, and age should not be a primary deciding factor in the decision for or against treatment. Compared with chemotherapy or surgery, radiation was less invasive and more tolerable for this patient. Because she lived in a nursing home, the patient was in a controlled setting where monitoring of any side effects could be more easily achieved.3 Overall, the benefits outweighed the risks, and the organizational culture supported the ethics of the treatment decision.
One challenge that had to be addressed was the need for daily anesthesia for 20 treatments. Monitored anesthesia care (MAC) would be needed to ensure patient safety and treatment accuracy.4 The complexity of the treatment also included the location of the tumor, the reproducibility of the patient’s position daily, and the safety of leaving the patient alone in the treatment vault during radiation.
Communication and teamwork Because outpatient anesthesia would be required daily in the radiation department, a multitude of questions arose. These questions included where the chart would reside, what documentation was necessary, who would recover the patient and where, how the patient’s nutrition would be maintained, whether the procedures would be reimbursed, and how the patient’s treatment would be scheduled in several different scheduling systems. In an attempt to answer these concerns, an e-mail describing the intent and nature of treatment was sent to various department heads. A conference call followed that included team members representing surgery, risk management, nursing, medical records, pastoral care/ethics, radiation therapy, and finance. The call drew upon the experience and knowledge of the entire health care team with the focus not on if the treatment could be given but rather on how it could be successfully accomplished.
Another challenge was communication with the nursing home facility. Daily transport from the facility was needed, after which the patient had to be brought to the radiation department and later picked up from the recovery area. Ongoing communication would need to include the daily patient status. The patient would need to be NPO from 6 am, which would result in two missed meals at the facility. Weight, calorie counts, and fluid intake needed to be closely monitored to maintain the patient’s physical and mental status.
Regular communication with the family was also essential. At times, one of the patient’s adult children came to the radiation department to be with her before her treatment and during recovery.
A successful hand-off results in the transfer of the necessary patient information and the turnover and acceptance of the patient’s care.5 To facilitate a smooth transition, the situation, background, assessment, and recommendations—known as SBAR—are needed.6 The Joint Commission reports that 65% of sentinel events are brought about by inadequate or missing communication.5 Development of the nursing plan of care with communication hand-offs was the principal challenge in this case.
The radiation nurses would start early in the morning with conversations with the nursing home staff. They would discuss the patient’s weight, her vitals, what kind of a night she had, her intake, and the status of the wound. The nursing home would hand off to the ambulance service. The paramedics who staffed the ambulance were usually those who transported her daily. They were cheerful, kind, and gentle with the patient. She often remarked how the boys would wrap her in a warm blanket when they came to pick her up. The next handoff was to the nurses in radiation. They would complete a nursing assessment and initiate an IV before summoning anesthesia.
The patient was treated under sedation and then taken to the recovery room accompanied by anesthesia and the radiation nurse. The next hand-off was to the nurses in recovery, who also tried to minimize external stimuli and limit the number of staff caring for the patient. She was discharged from the recovery room to the paramedics and back to the nursing home. The recovery room nurses would communicate to the radiation nurses how the recovery had gone. Throughout the entire process, the nurse was the hub of the communication complex. At the completion of therapy, the nurses followed up with the nursing home staff concerning dressing changes for the wound.
Consistency in personnel is important for patients with dementia as it gives them a feeling of security. The same nurses in the radiation department cared for the patient each day. The patient was placed in a holding room with minimal external distractions.7 Vitals were taken and an IV was started. One nurse spoke with the patient while another performed the tasks. The nurses told the patient jokes and questioned her about her past.
Dementia patients often retain long-term memory and as they speak of past events, they become more engaged
with their caregivers and retain a sense of self.8 In this way, the nurses learned that the patient’s mother was also anurse and that the patient had a horse named Bob when she was young. A daily routine was established with a minimal amount of staff change; this helped create consistency in care and helped the patient remain at ease. At no point during treatment did the pat- ient refuse therapy or any procedures.
At follow-up visits, the wound was healing well. After 3 months, no drainage, odor, or lesion remained. The forehead had healed. The patient remembered the nurses who took care of her. They told her the same jokes, and she still laughed.
This case reinforced two important nursing concepts.
Individualize the nursing plan of care:
· Assess individual patient needs in relation to the treatment
· Prioritize and assign responsibilities; standardize a logistical plan
· Communicate in a consistent, timely, methodical fashion that prioritizes patient needs; this is the core of effective nursing care.
Provide appropriate care for patients with dementia:
· Use direct, everyday language
· Minimize external stimulation, and approach the patient in a nonthreatening manner
· Use humor, and draw on the patient’s experiences
· Know who your patient is and what matters to the patient. Otherwise we would not have known about the horse named Bob. It is all really just about the patient.
The authors work at the Bob & Edna Meadows Regional Cancer Care Center, Provena Saint Joseph Hospital, Elgin, Illinois. Andrea Duval is the director, Jane Cosentino is the nurse navigator, and Karen Ottaviano is the charge nurse.
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