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Ne On s longer enough sit r s rt r By Michele Chaban MSW
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Psy choso cial issues with a c anc er dia gnosis, By Margaret I Fitch RN PhD of the illness The challenge for health care and chaplains etc can provide access for. providers is to be attuned to these variations patients to expertise that would be of benefit. The diagnosis and treatment of cancer assessing the need for supportive care in an Above all information communication. has a significant impact upon the person ongoing fashion Some patient assessment and support are critical to patients and. affected and those close to that individual questions that could be helpful at each clinic family members experiencing cancer Timely. The impact has physical emotional social appointment are access to relevant information to peer. spiritual informational and practical how are you managing right now with the support programs and sensitive. dimensions see Figure One Dealing with cancer and its treatment communication with health care. the impact creates a myriad of issues and what kinds of things are concerning you professionals have been reported by cancer. challenges for an individual his or her about your cancer right now patients as important elements in their. family and friends When these issues are what would be helpful to you right now in coping with cancer Health care. not handled appropriately they interfere with coping with your cancer professionals have a responsibility to know. the individual s ability to cope with the Some individuals living with cancer about community services and be able to. cancer experience influence their quality of require little assistance in managing with connect patients and families with. life and in some instances influence their their illness Once in possession of appropriate agencies Two services that. ability to carry on with treatment information relevant to their needs they would be of use to cancer patients and their. Various reactions to the diagnosis and mobilize their own support systems and families in finding out about other services. treatment of cancer will emerge Shock cope However others require more available in their region are. disbelief confusion sadness despair anger intensive supportive care interventions Cancer Information Services. and resignation have all been reported No two Individuals with unmet needs risk 1 800 263 6750 anyone may call this. individuals will have exactly the same experiencing undue psychosocial distress toll free number for information about. reaction Some will confront the situation and may require specialized assistance to cancer and cancer services. while others will withdraw Some will manage manage this distress Local Community Care Access Centre. the challenges within their situation while The specific interventions that best meet there are 43 CCACs across Ontario to. others will experience ongoing difficulties and individual patient and family needs will vary provide local access to community care. distress Confronting uncertainty and real or from person to person The interventions or services including home care. anticipated losses is a reality for all set of interventions that may be helpful to. Individuals living with cancer are one individual will not necessarily be helpful Dr Margaret Fitch is head of oncology. exposed to a spectrum of experiences within to another The intervention that may be nursing at Toronto Sunnybrook Regional. the cancer care delivery system which may helpful to an individual who is newly Cancer Centre. be categorized under prediagnosis diagnosed may be ineffective at a. diagnosis dialogue and referral treatment later phase of the illness The Figure One. rehabilitation survivorship recurrent very nature of coping with life. disease advanced disease requiring threatening illness and adapting. palliative care and for the family to the aftermath is influenced by. bereavement Individuals may enter the an individual s perception of the. cancer care system at various points and situation and the meaning that he. experience the spectrum in different ways or she assigns to the illness. over different periods of time For some Factors such as socioeconomic. their total experience may be related to level educational level social. screening For others they may experience support culture religion and. diagnosis treatment and rehabilitation and geographic location can influence. only be involved in routine follow up For what intervention will be most. others their experience includes recurrent effective We need to be prepared. disease or advanced disease to offer a range of interventions. Regardless of how an individual and from which patients may select. his her family enter and proceed through the Including other health care. spectrum of cancer experiences they carry professionals on the care team. their physical social informational i e nurses social workers. emotional spiritual and practical needs with psychologists psychiatrists. them These needs will vary from person to occupational therapists. person and vary in intensity over the course physiotherapists nutritionists. C anc er c are at York C entral Hospital,By Jane Anderson. Cancer care rounds held weekly are attended by case. We strive to provide patients with access to an integrated managers from the Community Care Access Centre head office as. system of programs including prevention early detection cancer well as nurses We have six acute care medical beds designated for. care and education pain and symptom management and three beds for longer term. Our team consists of an oncologist family physicians nurses complex palliative needs A furnished lounge room is located in the. with expertise in oncology a dietitian pharmacist social worker cancer care area This helps meet the needs of families who are. hospital chaplain and Community Care Access Centre case often in the hospital for long periods of time with their relatives. Jane Anderson is patient care coordinator in the oncology. medicine program at York Central Hospital, Ye e Hong p alliative Hill House A Richmond Hill hospice. c are servic es By Ann Gold RN The original Hill family home a three. bedroom bungalow was leased to Hill, A culturally The time has come as we enter the new. millennium for communities to establish,House Hospice by the town of Richmond.
Hill With round the clock nursing staff, sensitive a p pro a ch homelike settings for people with terminal supported by a core of volunteers trained in. illnesses who do not wish to die in hospital palliative care Hill House Hospice. By Stanley Zheng and cannot be cared for at home endeavours to relieve pain and suffering not. BSc MD PhD CCFP prolong life There is no,charge to the client. Most medical and health care Families and friends are. programs often have gaps in meeting the encouraged to participate in. needs of ethno cultural populations the care giving process. Linguistic and cultural barriers are Each visiting hospice. identified as major obstacles by many endeavours to meet the high. ethnic groups particularly Chinese standards of care provided. patients and families in accessing by both professional and. needed care volunteer persons We must, Chinese tradition enshrines family keep the CARE in caring. integrity and longevity Dying and death, mean pain and loss and are considered Ann Gold RN is the. social taboos There is a stigma attached founder of Hill House. to open discussions of such topics thus,making care planning difficult Many.
Chinese families find dying at home too,Charles R R Hayter MD BA MA FRCPC joins T SRCC. hard to manage if unsupported In order Dr Hayter was born in Brighton England and received his MD Queen s University. to alleviate anxiety and stress for in 1984 He did postgraduate training at Queen s and in England He holds an MA in. patients our program encourages drama and has a major interest in the history of medicine He is currently working on a. familial support and optimized book on the history of cancer programs and radiotherapy in Canada. resources Dr Hayter was on the staff of the Kingston Regional Cancer Centre. as an associate professor at Queen s University and a member of the. Stanley Zheng MD PhD BSc CCFP radiation oncology research unit He joined the Toronto Sunnybrook. is a palliative care specialist at the Yee Regional Cancer Centre in September of 1999 His areas of interest are. Hong Centre for Geriatric Care GU palliative oncology and the history of medicine We are delighted to. have him join our program, Dope and cope It is no longer enough studied the wish to die in a palliative compassion fatigue and trauma in family. continued from page 1 population Anecdotal evidence suggested caregivers. that requests to hasten death resulted from How one dies can have an impact on the. Justification of familial supports could a history of poor pain and symptom intergenerational health of a family. be easily argued Families who take on the management Laverty found that dying Families can have a sense of competency. primary caregiving role are not utilizing the persons claimed their wish to die resulted nobility and strength when they have. same resources as offered by institutional from their having become a burden to their successfully negotiated a safe passage for a. care Patients prefer to die at home family dying family member Families cannot and. Families report that this time can be a What is a burden From my clinical should not be expected to know or develop. period of unprecedented closeness Using a impression over the last 15 years burden is these skills through the course of life This. harm reductive paradigm clinicians with a person s sense of dependence on others a can be taught to families by a team of. advanced practice skills in palliative care sense of diminishing productivity and palliative clinicians who understand what is. help families develop the knowledge skills contribution to the family system a sense possible throughout the dying process. understanding and preparedness to of draining the family of financial and Palliative care is family care While. negotiate a death in the family Dying can social resources Burden progresses with palliative care is often seen as end stage. be a time of personal growth and familial time Perceptions of burden are to be found treatment of the dying Laverty s research. renewal despite the presence of impending in even the most supportive of families combined with the comparative literatures. loss Timely psycho educational and As we extend the lives of those living of traumatology compassion fatigue and. psychotherapeutic interventions can with life threatening illness time and intergenerational family health suggests. support families increasing dependency on the family early intervention avoids harmful. Similar to pre natal classes palliative system depletes and diminishes even the outcomes This speaks to the urgency with. counseling that is instructive and most functional families Life extension which we need to adapt to the current. preventive and not simply supportive can can often turn into death extension taking realities of dying rather than living in the. have a significant impact on a family s us to new places of human suffering and infancy of palliative care theory and. intergenerational health Treatment goals endurance Anticipatory tools such as practice. are to minimize suffering and maximize living wills and substitute decision making For further information contact the. the benefit experienced by those involved cannot fully support a dying person and intake coordinator at 416 586 4800. to search for and refine the meaning of family throughout the process of dying As ext 6293. dying and death in a family observers family members can experience. Clinical outcomes that further justify the compound grief reactions resulting from Michele Chaban MSW CSW PhD is. need for familial support are evident in a the trauma of a dying family member s director of the psycho social spiritual. recent study from the University of quality of life and death A lack of programs The Temmy Latner Centre for. Toronto s Centre for Bio ethics Laverty appropriate support over time enhances Palliative Care Mount Sinai Hospital. Interview with Russell G oldm an MD C CFP p alliative c are physician. with the Te mmy Latner C entre for Palliative C are Mount Sinai Hospital. How did you become Being able to provide comfort and support in twentieth page of the day I am ready to. interested in palliative care a time of crisis for a patient and their family throw my beeper out the window. Unfortunately I had no exposure to is extremely rewarding People are very Paperwork is also something I would. palliative care during medical school grateful and I am often overwhelmed by rather not do but I would not escape it in. Initially I became interested in palliative their gestures of appreciation From a any other field of medicine Economically. care during my clerkship amidst the professional point of view pushing the home palliative care is not as lucrative as. controversy of the Sue Rodriguez case I envelope of how medical care can be an office based family practice but it is a. thought that there must be a better way to delivered in a home setting also makes the comfortable living and the situation with. care for people in a similar situation As a work extremely gratifying regards to compensation for palliative care. resident I teamed with Dr Frank Ferris at is improving. Mount Sinai Hospital to carry out research Is your job very different from. on the attitudes of palliative patients This other physicians What do you think are the primary issues. eventually led me into a four month I would say that the setting for my job is in palliative care right now. fellowship in palliative medicine under the very different from most physicians I am on People do not have adequate access to. supervision of Dr Larry Librach At the end the road most of the day My car is my office an acceptable quality of palliative care. of my fellowship I joined the division of and my examining room is the patient s Inadequate funding and few resources are. palliative medicine at Mount Sinai Hospital living room or bedroom Looking after to blame A lack of awareness and poor. as a part time home care physician and later people at home can be extremely challenging understanding of palliative care both in the. became a full time partner at times We often care for very ill people public and professional spheres are also. with acute crises who do not wish to go to factors that slow the development of. What do you find most gratifying the emergency department This occasionally palliative care Professional education and. about your work as a home palliative requires a fair bit of creativity and ingenuity specialized training are essential if we are. care physician when crafting a management plan since you to be able to provide patients and their. I have a very high degree of job don t quite have the same level of resources families with optimum palliative care. satisfaction This comes as a surprise to available to you I also have the pleasure of There is an increasing demand for. many people as I am often asked Don t working with a supportive dedicated group palliative care services and not enough. you get depressed doing this work all day of visiting nurses and Community Care physicians providing palliative care to. In fact the opposite is true I find my work Access Centre coordinators Palliative care is meet that demand If even one twentieth of. to be very uplifting and rewarding Every truly a collective effort the resources that we devote to birthing. day I have the opportunity to learn from were dedicated to the care of the dying. wonderful caring people who are coping What aspects of your work then I think we would all have a lot less to. and struggling with extremely difficult do you find frustrating worry about when considering our own. situations This certainly has helped me keep No one really enjoys being on call but mortality. other aspects of my life in perspective it comes with the territory After the. Rese arch C orner The strategy of giving radiotherapy Esophageal fistula. By Rebecca Wong MBChB FRCPC twice a day has the potential advantages of Bronchial mucosal invasion. In this issue we would like to highlight an a short regimen and delivering a Esophageal stent in situ. ongoing study entitled Phase I II study moderately high dose of radiotherapy This For referral of potential study patients please. evaluating the efficacy of accelerated is the basis behind the design of this study call new patient referral at 416 480 4205. fractionation radiotherapy for the The study intervention consists of Any queries about this study please call. palliation of dysphagia in patients with external beam radiotherapy 40Gy in 20 Dr Rebecca Wong at 416 480 6165. carcinoma of the esophagus We ask for fractions 2 Gy per fraction twice a. your support and referral of patients who day five days a week Patients are The newsletter of the Rapid Response Radiotherapy. may be suitable candidates for this study followed on a monthly basis after Program of Toronto Sunnybrook Regional Cancer. For patients who are affected by completion of treatment Barium Centre is published through the support of. esophageal carcinoma dysphagia is usually swallow is performed at one month. the first and most devastating symptom and at time of dysphagia Abbott Laboratories Limited. This continues to dominate the patients progression The FACT quality of. remaining lifespan when the primary life questionnaire is administered AstraZeneca. disease cannot be eradicated Uncontrolled pre and post treatment and at time. local disease not only results in progressive of symptom progression The Berlex Canada Inc. dysphagia but also distressing respiratory primary study endpoints are. symptoms due to involvement of the probability and duration of Hoechst Marion Roussell. mediastinal structures causing airway dysphagia relief The study is. Janssen Ortho Inc, obstruction and fistulae formation From aiming to recruit 41 patients. the time of diagnosis of incurable This study is open to patients with Knoll Pharma Inc. carcinoma of the esophagus life Incurable primary or. expectancy is in the order of 6 9 months anastomotic recurrent carcinoma Novartis Pharma Canada Inc. External beam radiotherapy is frequently of the esophagus. the palliative treatment of choice This is Symptomatic with dysphagia Pharmacia UpJohn Inc. generally recommended over or in ECOG performance status less. combination with stent insertion especially than or equal to three Purdue Frederick. when a patient s life expectancy is long Life expectancy greater than. enough to warrant concerns for subsequent three months Rh ne Poulenc Rorer. extraluminal progression and stent failure Exclusion criteria SmithKline Beecham. due to tumour overgrowth Previous radiotherapy to the chest. Theratronics a division,of MDS Nordion,BOWEL OBSTRUCTIO N. Typ es and Symptoms All investigations and management options must be predicated on where the patient is at in the trajectory of this illness Patients with. very advanced disease and or who are not surgical candidates should not be subjected to needless investigations or hospitalizations. Type Symptoms, esophageal mild nausea Investig ations 5 HT3 receptor antagonists such as Ondansetron are ineffective.
preceding dysphagia Three views of abdomen Anti motility antispasmodic agents. vomiting or regurgitation Hypaque or barium bowel studies if appropriate where Oral Loperamide 4 6 mg po q4h for the first 24 hrs and then prn. gastric outlet severe nausea surgery possible and or where cause unknown If ineffective. Hyoscine butylbromide by constant subcutaneous infusion. frequent vomiting M ana g e m ent starting at 30 60 mg per day. epigastric abdominal I Surgical management Corticosteroids. distension First obstruction and not in the very terminal phase of Dexamethasone at an initial dose of 16 mg per day IV. dyspepsia illness surgical consultation to reduce edema. small bowel nausea and cramps Surgical possibilities include Octreotide. abdominal distension Resection of obstructed bowel Many will respond to conservative management. frequent vomiting Bypass procedures such as gastroenterostomy Hydration support with sufficient saline and potassium. initially often bile stained enteroenterostomies Once resolved soft or liquid foods with sufficient doses of. Decompression procedures such as an ileostomy and osmotic stool softeners Avoid any bowel stimulants. colon slowly progressive,colostomy or pro kinetic agents. abdominal distension, II Esophageal obstruction V Unresolved complete bowel obstruction. nausea and vomiting Esophageal stents, as late symptoms Significant management and ethical issues and no clear. A gastrostomy tube to maintain nutrition and hydration answers Careful counseling of patients and their families. vomitus may be feculent Also the option of no feeding tube Intravenous hydration should be short term only Counsel that. cramps early on III Gastric outlet or duodenal obstruction intravenous fluids are not nutrition the patient s condition will. rectum slowly progressive Early surgical intervention with bypass procedure not improve with fluid therapy and there is no evidence that. distension Double lumen gastrostomy tube to allow gastric drainage total parenteral nutrition TPN is appropriate for these patients. alternating constipation and feedings Support from palliative care consultants. and diarrhea Octreotide see below may decrease secretions and symptoms. nausea and vomiting A gastrostomy for drainage with or without another O ctre otid e. not pronounced enterostomy for feeding, An effective somatostatin analogue which is becoming one. until quite late IV Small or large bowel obstruction. of the standard treatments in bowel obstruction, Nasogastric tubes can be avoided in most patients Effects.
Potent opioids by subcutaneous infusion or by intermittent Decreases bowel motility. subcutaneous injections using an in situ butterfly needle Increases absorption of fluids and electrolytes from the bowel. By Dr Larry Librach with injection port or subcutaneous administration set Decreases gastrointestinal secretions. Palliative Care Specialist Anti emetic anti nauseant medication Dosage. Director of the Temmy Latner Centre for Haloperidol 0 5 5 mg q6 8h sc IV or by sc infusion 100 to 500 g every 8 12 hours sc. maximum 15 mg daily The higher dose range is necessary often only for a few days. Palliative Care Mount Sinai Hospital, Prochlorperazine 5 10 mg im or pr q6h avoid the IV route Can be given as continuous subcutaneous infusion. because of dystonic reactions Once symptoms are controlled the dose should be. Supported by an educational grant from Dimenhydrinate 50 75 mg q4 6 h im or IV second line drug gradually reduced unless symptoms reappear. Novartis Pharmaceuticals Canada Inc, Supplement to Hot Spot the newsletter of the Rapid Response Radiotherapy Program of Toronto Sunnybrook Regional Cancer Centre November 1999. MANA GEMENT OF RADIOTHERAPY INDUCED A CUTE G ASTROINTESTINAL TO XICITIES. Are a of Sm all bowel, c onc ern Oral c a vity Esopha gus Stom a ch larg e bowel Anal re ctum Perianal skin. Manifestations Dry mouth oral Esophagitis Gastritis Nausea Diarrhea bowel Proctitis Skin reaction. mucositis ulcers Vomiting obstruction, Common Head and neck Esophagus lung Stomach spine T10 L3 Abdomen and Pelvis prostate Pelvis perianal skin. radiotherapy cancers mantle mantle fields T spine mantle and upper pelvis bladder cervix. areas field mediastinum abdomen whole endometrium,abdomen e g ovary.
hemibody or total body, Important Exclude and treat Odynophagia Later onset Typically Examine for acute Careful history to Watch out for perianal. clinical any oral dysphagia manifest as commence abdomen and differentiate between abscesses. considerations candidiasis dyspepsia within 30 dehydration these conditions. nausea and minutes of indications that more frequently mistaken as. vomiting first aggressive therapy diarrhea,fraction including 1 small frequent bowel. of XRT hospitalization and movements with proctitis. resolve discontinuation of 2 small volume watery,after radiotherapy is bowel movements due to. completion warranted constipation with over,of radio flow XR may. therapy be necessary, Preventative1 Mouth washes with Dietary counselling Prophylactic antiemetics Counselling to reduce Optimize management of Ensure optimal skin.
baking soda 2 3x day against alcohol diet depending on degree of fibre content in their any diarrhea or condition pre treatment. Dental check up adjustments for emetogenicity start day diet when loose bowel constipation optimize treatment of any. Avoid smoking alcohol odynophagia of radiotherapy movements begin hemorrhoids incomplete. Ondansetron 8 mg od bid wound healing Use of corn,Stemetil 10 mg q4h prn starch for normal skin to. Gravol 50 mg q4h prn minimize skin reaction,Decadron 2 mg tid in. selected patients, Treatment of Tantum mouth washes Sulcrate liquid Zantac Ondan Lomotil Anusol HC suppositories Sitz baths. symptoms2 magic mouth wash analgesics e g codeine 150 mg bid setron 2 5 mg od Cortifoam enemas Dry desquamation. Analgesics e g codeine or morphine elixir Losec 8 mg bid Immodium 2 mg Proctofoam enemas Corn starch to skin. morphine elixir Mucaine 20 mg bid Decadron after each loose BM 2 3x day hydrocortisone 1. 2 mg tid max 16 mg Treat constipation or Moist desquamation. ensure Questran diarrhea Flamazine burrosol soaks,hydration 2 3x day. 1 Patients at high risk of developing toxicities should be considered for preventative interventions to minimize toxicities. 2 Patients with grade 1 2 mild to moderate toxicities can be managed with these interventions Patients with grade 3 4 severe to life threatening toxicities may require hospitalization and. discontinuation of radiotherapy and should be managed with the radiation oncologist. Magic mouth wash Mixture of diphenhydramine dexamethasone nystatin tetracycline water for details call T SRCC pharmacy. By Rebecca Wong MBChB FRCPC radiation oncologist Rapid Response Radiotherapy Program Toronto Sunnybrook Regional Cancer Centre. Supplement to Hot Spot the newsletter of the Rapid Response Radiotherapy Program of Toronto Sunnybrook Regional Cancer Centre November 1999.

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