Tom's Lung Cancer Diagnosis, Symptoms, and Co-Morbidities - Medical Case Study

Tom is a 55-year-old Aboriginal man diagnosed with advanced lung cancer and multiple metastases. Tom has consequently been faced with chronic and intense pain and breathlessness which makes it difficult for him to live and perform his tasks in day to day life. His lung cancer prognosis is increasing getting worse with time and both he and his family are aware of that.

Health needs of Tom

Tom needs to manage his pain in order to live a more comfortable and stress-free rest part of his life. He needs to reduce anxiety, fear of what the future would look like and the depression those fears induce. The palliative care team should discuss with Tom his fears, concerns, and issues and accord him the necessary help such as medication for pain management, therapy for relaxation etc. Tom needs to understand the state of his lung cancer illness, the goals of intended palliative care treatment, the potential benefits and possible burdens of the care plan, his expectations and care preference which would enable him live the rest of his life more comfortable and fully.

Concepts and principles of palliative care

Palliative care is referred to as specialized medical care for people with serious illnesses such as lung cancer in this case. The focus is to provide relief from the symptoms, pain, and stress. Palliative care aims at improving the quality of life for both the patient and his family. Palliative care has to be provided by a group of health specialists which include palliative care doctors, nurses, and social workers among others. The group works in partnership with the oncologist and other healthcare providers to manage the pain and symptoms of the illness in this case pain and breathlessness.

The principles of palliative care incorporate those of good clinical practice, regardless of the patients illness, where the patient is under care, his social status, religion, culture or education status.

In order for palliative care to work effectively, the following attitudes and principles should be applied

A caring attitude- Tom requires being shown concern, sensitivity, compassion and empathy by his family and the people around him which will enable him to feel that he is not suffering alone and that there are people who care about him. The concern should also extend beyond the patients medical and social work problems and should incorporate all aspects of his suffering. There should be no judgmental attitudes towards the patient especially since Lung cancer is mainly caused by smoking where the patient blames himself for the suffering. The fact that Tom is an aboriginal man, in this case, should not be used for instance as a basis for prejudice.

Consideration of individuality- for optimal palliative care to be realized, each patient should be considered unique individually, without collective generalization based on the similarity of the health problem. The palliative care team should recognize that each patient has unique psychological characteristics which can influence the suffering of the patient to a great extent. These factors of uniqueness in individual problems in a given health illness such as lung cancer patients, in this case, should be taken into consideration by the palliative care team for it to work effectively.

Cultural factors- cultural factors such as ethnicity, race, and religion among others have been known to greatly influence the patients level of suffering and those differences should be considered while planning for the care of the patients.

Consent- palliative care works best when the patient, or his family or guardian consents or agrees with the approaches applied in the treatment of his illness. In this case, for instance, Tom and his family are likely to respond more positively to the treatment approaches in his palliative care if hes made aware of the consequences and reasons for their applicability and agrees to them.

Choice of site for palliative care- the location of where the care plan is delivered is an important factor in determining the outcome of the care plan. Both the patient and his family should be included in determining the location of conducting the care. For Toms case, his lung cancer which is a terminal illness, home treatment is recommended.

Good communication- communication is an important factor especially for people working in a group as it ensures coordinated delivery of each persons role in the whole system. Healthcare professionals should communicate with each other as their ability to deliver effective palliative care depends on sound communication. Discussions and consultations with the patient and his family are also crucial in realizing optimal palliative care.

Potential nursing interventions for Pain management in Toms advanced lung cancer

In most cases, pain originates from multiple factors and impacts greatly upon both the physical and psychological functioning of the patient. Pain management therefore needs multi-disciplinary evaluation so that each aspect of the pain is addressed. Pain is categorized into two types; acute pain and chronic pain. Patients with advanced lung cancer such as in the case of Tom experience acute pain which has a specific onset and a limited predictable duration, identified with incidences of sweating, pallor and papillary dilatation. The major causes of pain in patients with advanced lung cancer are; skeletal metastatic disease (34%), Pancoast tumor (31%) and chest wall disease (21%). Pain management in Toms condition requires the application of analgesic treatment which reduces pain without inducing drowsiness and unconsciousness.

The following are some of the common analgesics for pain management that can be used in addressing Toms condition:-

Opioids- morphine as one of the strong opioid has been known to greatly manage lung cancer. Morphine, like other strong opioids, should be titrated until the desired analgesic benefit is achieved. The palliative care team, however, needs to administer only small amounts to Tom to mitigate incidences of drowsiness so that he can be awake and be able to tell tales to his people. Other opioids that can be used in Toms pain management include oxycodone, methadone, hydromorphone, and fentanyl. The patient needs to be informed of the potential side effects of these opioids such as Opioid-Induced Constipation (OIC) and how to deal with them. The palliative care team should opt for opioids with better analgesia and less constipation to facilitate an enhanced quality of life for Tom.

Adjuvant analgesics- include drugs which have analgesic benefits and are useful in pain management especially for patients with chronic pain eg Tom. Adjuvant analgesics such as Tricyclic antidepressants are deemed to enhance the availability of monoamines at synapses within neural pathways that are part of the descending pain-modulating system.

Pain management interventional procedures involve an interruption to or modification of nerve conduction with the aim of diminishing pain from a specific target area. The procedures may be considered to be either non-destructive or destructive. In non-destructive procedures, nerve blockade or modulation is achieved by the deposition of reversible pharmacological agents. These may be given by bolus injection or catheter placement which allows for continuous delivery of pharmacological agents. Its important for the palliative team to communicate with the patient and examine the potential benefits and possible risks in the identification of a pain management intervention which will enable him to live a fulfilling quality life.

Potential nursing interventions for Breathlessness control in Toms illness

Lung cancer has been known to cause breathlessness and discomfort with breathing to the patients and is one of the most difficult symptoms to manage in advanced cancer (Bailey 1995, Hately, 2003). Breathlessness can lead to physical and emotional distress, social isolation and a reduced quality of life (Booth, 2008). Breathlessness is extremely common in patients with lung cancer and other primary cancers and, along with pain and fatigue, is a core symptom that can persist at the end of life (Solano, 2006).

Studies have shown that 10-15% of patients with lung cancer experience breathlessness at diagnosis and 65% will experience breathlessness at some point during their illness (Reuben and Mor 1986, Bredin, 1999). Although the majority of patients with lung cancer experience breathlessness as death nears (Ripamonti, 1999), management of this symptom remains unsatisfactory (Booth, 2008).

Breathlessness restricts both the general functioning and social functioning of the patient, leading to a loss of independence and of role (Zhao and Yates 2008). This as in the case of Tom results to increased frustration, anger and depression. (Gallo-Silver and Pollack 2000), notes that when patients experience difficulty in breathing, intense feelings of fear and panic may be evoked leading to feelings of anxiety, hopelessness, and fear of impending death (Twycross, 2009).

Breathlessness in cancer patients begins episodically and becomes constant as the disease progresses. (Booth, 2008) notes that in advanced lung cancer as in Toms case, breathlessness is caused by multiple factors whose underlying causes are irreversible. The only option, therefore, available for improving Toms quality of life is breathless management.

Pharmacological interventions such as opioids, nebulised drugs, anxiolytics, bronchodilators, and oxygen are in most cases applied after medical approaches such as radiotherapy and chemotherapy fail to resolve breathlessness in cancer patients. In Toms case, however, the cultural factor of being an aboriginal patient who believes in traditional healers and in traditional medicine, Pharmacological interventions may not be particularly an open option for him. In this regard, the palliative care team should apply non-pharmacological interventions in an effort to improve Toms quality of life.

The following are some of the non-pharmacological nursing interventions that Toms palliative care team can use in managing his symptom of breathlessness:-

Breathing exercises and positioning- Breathing exercises such as diaphragmatic or deep breathing are considered to be effective in helping the lungs function optimally and promote feelings of relaxation and stress reduction. Diaphragmatic breathing is effective as the more the abdomen moves when breathing the more the lungs are filled and emptied, improving the gaseous exchange of oxygen and carbon dioxide (Gallo-Silver and Pollack 2000). These exercises are easily applicable to Tom and can have a beneficial impact on how he feels about his breathlessness. Patient positioning also improves the breathing of a patient. The palliative care team should keep Tom in a supported high side-lying, sitting upright with arms supported by pillows, leaning forward with his arms supported on pillows, all of which will enable the diaphragm to move freely increasing his lung capacity. Henderson, 2008 noted that positioning reduces muscle fatigue by supporting the accessory muscles.

Activity planning- breathlessness is often triggered when the patient spends a lot of energy on an activity, and should, therefore, be minimized. The palliative care team can for instance position chairs in Toms house for him to take rests in between activities so that he can conserve energy. He should also be discouraged from performing heavy duties such as lifting and carrying heavy goods.

Complementary therapy- cancer patients are increasingly using complementary therapies together with main treatment to manage breathlessness and improve their quality of life (Vickers and Cassileth, 2001). Therapies such as aromatherapy have been known to reduce anxiety and dis...