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Yesterday I was reviewing a patient’s complex oncology case and trying to see if there had been any gaps in care. This was an approximate 60 year old male with a diagnosis of gastric cancer who was diagnosed in 2010 unexpectedly with just some acute onset abdominal pain and bloating, and nausea and occasional vomiting with eating.
He was not surprised by the nausea and vomiting, as he had a history of GERD that he had been treated for, and depending on his dietary modification, that could sway how he was feeling.
His fatigue was abnormal for him, as was his weight loss of about 20 lbs in a month, and he also noted that his bowel movements had changed in consistency and also in color. He had been a 2 ppd smoker that he had stopped over 10 years ago.
He presented to the ER due to severe pain in his chest and back with every cough. A chest X-ray revealed that he had a pneumothorax, and a chest tube was inserted immediately in the EOD. At that time, he had sudden relief of all pain and discomfort and was able to breathe easier without all the anguish that he had been having prior.
I had gone into the room to evaluate his status and begin to see how he was doing and if there were any services that he would require when the time was right for him to go home, and after and Oncology consult was done. He was a very pleasant gentleman, and we sat and spoke for some time.
I asked him if he had any idea about what stage his disease was. He told me that the Oncologist had told him that it was a stage IV, and that surgery was not an option. He had been receiving chemotherapy, even just prior to this admission, but that there were signs that it was not working. He was beginning to not feel well again, just like he was when he was first diagnosed.
“So”. I asked. “You know then that you are not going to be cured? That the doctor is looking for a way to just keep this disease stable so that is does not grow anymore. Is that how he explained it to you?” “Yes”, he said, and in the same breath he told me that when he was diagnosed he was strong for his wife, but he knew, he just knew at that moment that the diagnosis itself was what would be the end. He would not be cured. He felt it in him, even before they told him.
“Did your wife know?” I asked. He looked at me for what seemed like minutes. “How do you tell someone who does everything for you that you have given up the fight and that you are done and ready for it to be over because it is too much”?
“It is too much for her everyday. Imagine, if you will, that your husband is now your baby. You have to change him because of his incontinence, help him to the bathroom; I can not take a bath or toilet alone. Brushing my teeth takes a team. I have to rest days in advance to go to the doctor’s office. She is by herself all the time because I am not all there, but she really is not. She is responsible for a child.”
He made me think that this part must be increasingly hard on the caretaker, whomever that is, as well as the new dynamic that needs to be established between a couple. Either the new dynamic is able to work, or not. Marriages and relationships on this crazy scale are suppose to work 50%/50%, but what if for an indefinite amount of time it is 110%/-10%, what then? Who could stand that kind of pressure and demand?
Remember, this is also a health situation, so there is also the guilt of it all if you cannot. How do caregivers manage? And how do they manage if the member he or she does not acknowledge the need for assistance or outside help.
I asked my pt if he ever spoke to anyone, or is speaking to anyone currently about his diagnosis and all the stressors involved on a day to day basis. He did state that his PCP referred him to speak with a Psychologist and he is also on medication for depression. His wife is also on medication and has a support group she found online and that helps her greatly.
I expressed how brave I thought he and his spouse were for acknowledging the problem before there actually was one, and for also assisting her in obtaining help. He smiled and said, “We have a great PCP.”
After I was done speaking with this pt, I walked out of the room thinking about how many ways that our patient’s have difficulties, stressors, financial issues that can cause them to become anxious, depressed, not think clearly. And, again, not just the pt, but imagine being the support person, never doing a bill in your life and low and behold, it is all on you.
Depression is insidious. It is painful, damaging and sneaky. Most of the side effects that pt’s have are signs of depression-weight loss, being so tired that you don’t want to get out of bed, no energy, weakness, crying (d/t disease/lack of support/fear).
Sometimes I think we glance over these and assume that these will resolve as the side effects of the medication resolve or the member gets use to it. In fact, it does not. There is no harm in discussing with our patients the benefits of seeking help during this difficult time to speak to a psychologist for talk therapy, a psychiatrist for medication and talk therapy as well. Also, local support groups for them and their families to go to, so they do not feel alone.
The American Cancer Society is a god reference for patient’s who have cancer. It has local links for support groups and some of them even do sessions over the phone.
Defeatdiabetes.org is a great website for diabetic support. If you want to find resources for your patients, you can. It is not hard to empathize with them and make them understand that first, you are here for them and you understand what they are going through so that you establish that relationship and they will come to you with any issues they have, and second you will go out of your way to find what they need in order to support the needs they do have. That is what case management is all about. Supporting needs and filling in gaps.
Cassie is an eleven year cancer nurse with inpatient and outpatient experience as well as case management and managed care experience. She has also utilized the skills and compassion that it takes to be an oncology RN to work as an inpatient hospice RN. Cassie has a true love of nursing and her patients.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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