Care of the Cancer Patient

A Quick Reference Guide

Wesley Finegan, Angela McGurk

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315358109
• Topic: Medicine
• Subtopic: Anesthesiology & Pain Management

This work includes a foreword by Elizabeth Rogerson. Head of Education and Development, International Virtual Nursing School Head, Distance Learning Centre (Nursing and Palliative Care), University of Dundee. It considers all the patient's symptoms and all the information available to us, then assesses the symptoms, signs and information given, using this to choose the appropriate remedies for the problem, and extra information will be offered where available and appropriate. This easy to use, evidence-based guide offers practical resources for every day use. Well laid out, with a simple alphabetical format, "Care of the Cancer Patient" covers the management of common problems, contains basic explanations of pathophysiology and relevant pharmacology, and includes vital guidance on new treatments and scientific papers. It is ideal for non-specialist doctors, nurses, carers and other health professionals who look after patients with cancer-related symptoms. 'This book recognises the complexity inherent in the cancer journey and places a spotlight on the human face of health care management, specifically on the ability to provide careful, individualised and sensitive management of symptom control that aims to make a difference to the patient's quality of life. It is written in a manner that is acceptable to professionals, patients and carers alike. This book adopts a unique approach to symptom management in palliative care, inviting the practitioner to consider the possible causes of the symptom, and then assess the patient with these in mind. Paying attention to the pathophysiology of the symptom and respecting the individual needs of the patient, one is guided to make a logical choice of treatment by thinking about the pharmacological actions of the available drugs. This is a book to be on the desk ready for quick reference, not stored on a shelf in a library.' - Elizabeth Rogerson, in the Foreword.

Part 1

Communicating with the patient

Chapter 1

Basic issues in communication

All around my bed is a great big curtain;

There’s someone there behind it, but I don’t know who.

It sounds to me like doctors, but I can’t be certain,

And specialists and nurses, too.

They’re talking very quietly and muttering together

About the need for surgery, or therapy, or what.

It all sounds pretty dodgy, and I don’t know whether

I’m the subject of their little plot.

Christopher Matthew¹

Introduction

Much has been written on the subject of communication with cancer patients, and many training courses are available, which serves to highlight the importance of this topic.

There are a number of issues that can arise when we are speaking to patients. These include the following possible problems:

• anger

• collusion

• confidentiality issues

• denial

• distancing oneself from the patient

• getting too close to the patient

• refusal to talk.

C Consider

What are the perceived problems with our communication skills when dealing with cancer patients?

Patients sometimes say that:

• they were told too little

• they were told too much

• they were told too quickly

• they were not able to understand what was said

• they did not believe what they were told.

A Assess

• What does the patient already know about their illness and prognosis?

• Who gave the patient this information?

• How accurate is this information?

Be aware of the risk that patients may sometimes quote verbatim what was said to them. Does this mean that they understood the message and its implications? We can teach parrots to recite sentences accurately, but they don’t necessarily understand the meaning!

℞ Remedy

It is important to establish ‘common ground’ before entering into further discussion, especially when one has bad news to impart.

• Find out, preferably in their own words, exactly what the patient knows about their diagnosis, their expectations of the treatment available and their prognosis.

• How much do they want to know now and how quickly do they wish to be told?

There are some basic ‘rules’ that can be quickly summarised as follows.

Ambiguity must be avoided at all costs. Use language that your patient understands.

Check the patient’s understanding by asking them to summarise the conversation in their own words. Repetition of phrases does not prove understanding of the message.

In this respect, let us share a true story. WF was attending an outpatient clinic as a patient when this happened.

An elderly Scottish woman emerged from the consultant’s room beaming with happiness. She approached WF and said ‘What a lovely doctor and what good news he gave me. He is going to give me the “cream o’therapy”. Poor you, you’ll only be getting the milk!’

Before WF had an opportunity to explain that she might have misunderstood the term ‘chemotherapy’, the patient had scuttled out of the waiting room.

As a patient, what was WF’s responsibility?

Cue-based questions like ‘What was that like for you?’ can invite open honest sharing.

Listening can be active or passive.

• ‘Active’ listening involves eye contact and appropriate body language to encourage the patient to talk.

• ‘Passive’ listening offers less of your attention, and patients may tend to say less.

Note taking is essential, but patients may think that you are paying less attention to them. Agree with the patient that you may take notes, why you are taking them and who else may see them (assure them of the confidentiality of the notes that are written), and let them see that you are still giving them your full attention.

Observe the patient. Do their verbal and non-verbal messages say the same things?

Questions should be ‘open’ to encourage the patient to offer the information in their own words. ‘Closed’ questions have only one possible answer (e.g. ‘What is your date of birth?’). These do not encourage the patient to ‘open up’ and talk freely. Leading questions should be avoided, as they often result in biased answers intended to please the person who is asking.

Summarise the consultation at the end, making sure that the patient has taken in what you were saying.

Time is always the enemy! No matter how much time you have, the patient may think you are too busy to talk. Reassure them if you have time to have a full discussion. If not, agree a mutually acceptable time for a return visit to discuss the issues in depth.

Another anecdote. WF was attending for radiotherapy. An elderly woman emerged from the treatment room and saw him sitting outside.

‘Do I look all right?’ she asked in a conspiratorial whisper.

WF, recognising that he is a mere man, assured the lady that she looked fine.

‘I don’t glow, do I?’

‘No, why should you?’

‘All I know about radium is that my husband used a special paint to paint the instrument dials on war planes. I think it contained radium and the paint glowed green in the dark.’

‘I don’t glow in the dark, so you won’t either.’

‘That’s good. I just wondered. He did great work. He used to suck his paintbrush to get a nice fine point to do fine work. Poor love died of cancer of the tongue. I don’t know how, for he never smoked.’

On this occasion, because WF knew both the radiographers treating him, he recounted this story. The staff admitted that, due to pressure of time, the woman had not received an explanation of the treatment schedule, nor had she had the opportunity to discuss any fears or anxieties.

Before we criticise, however, remember that we all live in the real world. Don’t we all face the same enemy – time, or lack of it?

Use the concept of working in TANDEM with the patient to help them to think about the questions they might wish to ask now or at a later time (see page 297). This allows them some control over how much they are told and how quickly they have to come to terms with the information.

E Extra information

It is a well-documented fact that on hearing the word ‘cancer’, the shock can be such that the rest of the conversation is lost and the patient may subsequently deny having been given significant pieces of information.² Interviews have been taped so that the patient and their family can listen to them afterwards. Patients may complain that they were actually told too much, but at least this technique allows them to listen at their own pace, and to listen more than once, and it also avoids any misunderstanding or inaccurate reporting by the patient and their relatives about what was actually said.³

It is of interest that the use of taped interviews in a general practice setting increased patient recall, improved satisfaction with the treatment offered and helped patients to share the information with others involved in their care. However, it did not have any effect on adherence to the advice given or on anxiety associated with the presenting problem.⁴

References

1 Matthew C. ‘Touch and go.’ In: Now We Are Sixty (And A Bit). London: John Murray; 2003.

2 Fallowfield LJ, Baum M, Maguire GP. Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer. BMJ. 1986; 293: 1331–4.

3 Hogbin BJ, Fallowfield LJ. Getting it taped: the ‘bad news’ consultation in a general surgical department. Br J Hosp Med. 1988; 41: 330–33.

4 Liddell C et al. Giving patients an audiotape of their GP consultation: a randomised controlled trial. Br J Gen Pract. 2004; 54: 667–72.

Further reading

• Brewin T, Sparshott M. Relating to the Relatives. Oxford: Radcliffe Medical Press; 1996.

• Campbell S. A project to promote better communication with patients. Nurs Times. 2006; 102: 28–30.

• Hobma S et al. Effective improvement of doctor–patient communication: a randomised controlled trial. Br J Gen Pract. 2006; 56: 580–86.

• Kirk P, Kirk I, Kristjanson LJ. What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ. 2004; 328: 1343–7.

• Lugton J. Communicating with Dying People and Their Relatives. Oxford: Radcliffe Medical Press; 2002.

• Sheldon F, Oliviere D. Family information and communication – what works? Eur J Palliat Care. 2005; 12: 254–6.

• Surbone A, Zwitter M. Communication with the cancer patient: information and truth. Ann N Y Acad Sci. 1997; 809. (This is a 500 page+ volume devoted to this subject, dealing with virtually every culture worldwide.)

Chapter 2

Listening effectively: ‘ALWAYS REACT’

Jan Pederson

One of the best pieces of advice ever given to doctors, nurses or other health workers is that each time they see a patient, they ask themselves two questions.

1 What can I do for this patient?

2 What can I learn from this patient?

There is always something to do and there is always something to learn.

Anon.¹

Introduction

There is so much more to listening than just the verbal messages that the patient gives us. Everyone constantly sends out non-verbal signals, and effective assessment involves picking up the cues and also being aware of our own ‘non-verbal leakages’ of emotions and feelings.

Some years ago, when working as a district nurse with one of the authors (WF), I became fascinated by the vast numbers of simple but easily overlooked non-verbal signals that are being transmitted but frequently missed.

We agreed that it is only when you ‘always listen with all your senses’ that these have any hope of being picked up, whether it is appropriate to deal with them or not at the time. We agreed to try to do this – ‘always,’ We were amazed both by the things we had missed and by the non-verbal messages that we ourselves might be transmitting.

This is a huge subject, and I can only scratch the surface layer, but here are ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Preface
• About the authors
• Acknowledgements
• Resource texts
• What standards of treatment and care can the patient reasonably expect?
• Part 1 Communicating with the patient
• Part 2 Therapy review
• Part 3 The problem of pain
• Part 4 Common symptoms and their management
• Part 5 Practical issues in the care of the patient
• Part 6 Ethical, moral and religious issues
• Part 7 Quick practical guides
• Appendix
• Index