Supportive Management of the Patient With Pancreatic Cancer:

The oncology nurse attends not only to the physiologic needs of the patient with pancreatic cancer but also to the educational, economic, logistic, and psychosocial factors that impact on quality of care. Managing patient care from admission through discharge in today's short hospitalization periods, the oncology nurse's vigilant attention to "patient care maps" helps keep the multidisciplinary health-care team on schedule, contain costs, and maximize hospital resources. Patient and family education provided by the oncology nurse, along with take-home reference materials, facilitates adjustment to the cancer diagnosis, encourages patient compliance with treatment procedures and pain management, and can cut health-care costs by eliminating unnecessary post-discharge trips to the doctor's office or emergency room. Oncology nursing assists patients with pancreatic cancer along the continuum of care via whatever pathway is chosen. [ONCOLOGY 10(Suppl):23-25, 1996]

Introduction

The oncology nurse is the singular thread that runs throughout the entire continuum of care of the patient with pancreatic cancer--from admission through discharge and post-discharge. An amalgam of caregiver, listener, educator, cost-containment specialist, and advocate, the oncology nurse becomes a familiar face in the often confusing medley of "white coats" whirling in and out of the patient's room.

Patients arrive at the hospital with a wide range of information and misinformation, expectations and fears. As one of the first health-care professionals to meet and talk with patients, the oncology nurse assesses their knowledge of their medical condition and provides supplementary education to enhance understanding and cooperation. Despite the urgent nature of therapy initiation, patients need to be adequately prepared not only physiologically but also psychologically. By discerning patterns of family support, coping, and communication, the nurse can adopt a teaching style that suits the individual patient [1].

Providing Patient and Family Education

Listening plays a vital role in patient and family education. To effectively and respectfully communicate with the patient, the nurse must listen patiently and answer questions clearly, candidly, compassionately, and as positively as possible, taking cues from the patient as to what he or she wants to know, as well as when and how to convey this information. During this time of incapacitating fear and insecurity, some patients are better able to deal with cancer by leaving most of the information and decisions to their doctors. For these patients, learning about their condition and participating in medical decisions are threatening and (for them) may make coping more difficult.

Other people cope by learning all they can about their cancer and its treatment. They arrive with many questions, are armed with reviews of the medical literature regarding their condition, and struggle to make sense of scientific journal articles replete with seemingly cryptic terms and data. To add to patients' confusion, health-care professionals may speak to them using an alphabet soup: CT, ERCP, PTC, CEA. The oncology nurse helps by deciphering jargon, defining terminologies, and translating complex medical concepts into language that the patient can comprehend.

A supply of teaching materials, written at no higher than a sixth-grade reading level, are welcome handouts that can be shared with patients and their family members. Oncology nurses also tend to collect files of photocopied articles, textbook pages, and other documents that have helped illustrate procedures or answer patients' questions in the past. A touch of humor sprinkled throughout these materials not only improves dispositions but also makes learning more palatable for some people, and can be useful in helping patients remember important points. Other patients may respond better to a curriculum spiced with appropriate inspirational poems, quotations, and life-affirming thoughts. The key is to size up the patient's needs and be sensitive to them.

As an introduction, nearly all patients and their family members can benefit from an elementary review of the anatomy and function of the pancreas. A simple illustration of its location with respect to neighboring organs will help patients visualize where their cancer is and how it will be treated.

Educational intervention by the oncology nurse increases patient compliance, heightens patient and caregiver expectations regarding side effects of both the disease and its treatment, and helps eliminate unnecessary trips to the doctor's office or emergency room--all of which can impact on health-care costs. Good communication demystifies frightening medical procedures. Preparing the patient and family for what to expect after surgery is an example. This information eliminates surprises, such as the appearance of IV lines, nasogastric tubes, drains, and visits from consulting oncologists.

Explaining the patient's role in the recovery process aids compliance with hallway walking, deep-breathing exercises, and taking pain medications. Options for additional treatment following surgery, including chemotherapy and radiation therapy, are also described, along with accompanying expectations and outcomes. Nonsurgical management of pancreatic cancer must also be explained to help patients make informed decisions about their individual treatment plans.

Pain management is another critical area to be addressed by patient education. Stoic attempts to withstand pain may be rooted in machismo, religious discipline, or misunderstandings about drug addiction and abuse. Consequently, patients and their family members must be taught about the crucial role of pain medication.

The oncology nurse at a large academic research center has the additional role of explaining what clinical trials are and what it means to take part in them. Before patients and their families can make a decision about enrolling in a trial, they must understand the research process, including how clinical studies are structured so that two identically matched patient groups are randomly assigned to receive either the standard (accepted as therapeutic) treatment or the new treatment under investigation. Patients choosing to participate in a clinical trial must sign consent forms (which must be written in simple, understandable language) and be thoroughly aware of the investigational nature of the study and the inability to predict the outcome of the treatment. Patients need to be reassured that they will not be penalized or receive any change in care should they decide not to participate in a clinical trial.

Patient Care Pathways Track Progress

Proper patient management, including careful assessment, appropriate interventions, and thorough patient and family teaching, greatly enhances recovery and rehabilitation [1], but managing patient care throughout today's express hospitalizations requires a vigilant system for keeping on schedule. Interdisciplinary "patient care maps" facilitate the tracking process by providing detailed checklists for patient monitoring, treatments, lines and drains, medications, activity, diet, tests, consultations and referrals, patient teaching and discharge planning, and evaluation of outcomes. A simplified version of the patient care map is provided to the patient and his or her family so that they can anticipate what will happen each day.

When the patient deviates from the care pathway for some reason, an amended patient care pathway record sheet may be needed. In many instances, standard alternative pathways can be employed. For example, when a planned resection cannot be performed and palliative procedures, such as a single or double surgical bypass, are substituted, the health-care team switches to a prepared alternative patient care pathway. Family education regarding the new track is begun as part of the new schedule.

When the pathway check sheet system is working smoothly, the entire interdisciplinary team follows a prescribed course of action. For example, if a patient develops diabetes as a complication of treatment, the equipment for home glucose monitoring shows up in the patient's room the next day and diabetes education is automatically added to the family's program. Diligent attention to patient care mapping ensures not only efficient but also cost-effective management of multidisciplinary health-care resources throughout the patient's hospital stay.

Discharge Planning Begins on the Day of Admission

Today's cost-containment system underscores the need for well-engineered discharge plans and family education, as a large portion of the patient's care must now be undertaken at home. Because abbreviated hospitalization periods allow time only for a crash course in home health care, oral instructions must be accompanied by detailed written supplements or videos for later reference.

Take-home instructions must be clearly written, highlighting such cautions as physical activity restrictions and symptoms of infection. Discharge directions should also address diet, newly prescribed medications (such as insulin and enzymes), continuation of previously prescribed medications, pain control, bathing and showering, suture line care, wound care, bile tube care, when to call the doctor (eg, if symptoms of infection develop, skin or eyes become yellow, or uncontrollable pain occurs), and how to arrange for follow-up appointments. Laminated handouts on the "Skin Cleaning Procedure" and the "Tube Flushing Procedure" are handy for either family members or home/hospice nurses to use at the bedside. Videos demonstrating such procedures are excellent additions to the discharge package.

The oncology nurse gets to know the patient with pancreatic cancer and his or her family better than the other members of the health-care team and can "red-flag" potential discharge problems that other staff members may not notice, such as difficulty in mastering glucose monitoring or an inadequate or unstable support system for home care.

The whirlwind of interdisciplinary health-care procedures addresses the acute physical needs of the hospitalized patient with pancreatic cancer, but someone must also prepare the patient and family for living with the condition after discharge. Oncology nursing involves much more than treating cancer--it takes a holistic look at the patient's now-upturned world and attends to educational, physiologic, economic, and psychosocial needs, which will help the patient cope with the disease and its symptoms to enhance quality of life.

References:

1. Frogge MH: Gastrointestinal cancer: Esophagus, stomach, liver, and pancreas, in Groenwald SL, Frogge MH, Goodman M, et al (eds): The Care of Individuals With Cancer 2nd ed,, p 806. Cancer Nursing: Principles and Practice, part VI. Boston, Jones and Bartlett Publishers, 1992.