Chapter 6: Palliative Care for Cancer and Communicable Diseases
Learning objectives for this chapter
By the end of this chapter, we would like you:
- To explain the goals of the palliative care management of advanced / metastatic cancer.
- To describe the management of the complications of advanced / metastatic cancer.
- To discuss the principles associated with the provision of palliative care to people with HIV/AIDS, including the differences between this care and other types of palliative care.
- To describe the correct use of, and complications associated with, antiretroviral (ARV) medication for patients with HIV/AIDS in the palliative care setting.
- To implement palliative care strategies to manage the other complications of HIV/AIDS.
Palliative care for cancer
In the UK, people may receive palliative care for a variety of different types of cancer; generally, however, this cancer is advanced and metastatic. Breast, prostate, lung and bowel accounted for more than half of all new cancer diagnoses in the UK in 2013.
A cancer diagnosis, even one which involves a good prospect of recovery, is frightening for many people. Treatments often have a significant negative impact on a person's health, both immediately and in the medium- to long-term. People are often very concerned about end-of-life cancer care; however, with effective palliative care can address this. Nurses must work closely with patients - and their family, carers and significant others, as appropriate - to clarify their expectations and document their preferences.
Management of cancer in the palliative care setting
Palliative care for cancer aims to: (1) relieve symptoms, and (2) improve the patient's quality of life. Often, palliative care for cancer involves:
- Therapies to reduce or control the side-effects of cancer treatments.
- Therapies to reduce the size of cancerous tumours
Cancer is associated with a variety of complications. The following discusses these complications, and strategies which can be used to effectively manage them.
- Metastatic spinal cord compression: cancer spread can result in collapse of one or more of the spinal vertebrae, causing pressure, oedema, ischaemia and eventual infarction of the spinal cord. Less commonly, a cancerous tumour can directly compress the spinal cord. Causes various neurological symptoms, including problems with mobility, weakness, difficulty walking, changes in sensation and cognitive deficits and pain. Rapid onset is typically a predictor of poor outcome.
Corticosteroids and adjuvant analgesics, are a key treatment. Management may also involve interventions to relieve pressure - including surgery, radiotherapy and chemotherapy. Allied health professionals are frequently involved, to respond to their often rapid changes in functional ability.
- Bone metastases, pathological fracture and hypercalcaemia: bone metastases are common, but may not cause symptoms. Where metastases are symptomatic, management focuses on pain relief. Chemotherapy and radiotherapy may also be administered with the goal of reducing symptoms. Bisphosphonates may be prescribed to reduce risk of fracture and hypercalcaemia. Techniques such as cement injection and percutaneous ablation are used to manage bone metastases unresponsive to conventional treatment.
There is significant risk of pathological fracture. Risk of pathological fracture is identified using scoring tools and x-ray images, and reduced through preventative interventions such as prophylactic fixation. If a fracture does occur, it is treated as a normal fracture would be.
Patients with bone metastases are also at significant risk of hypercalcaemia. Factors released from the immune system and / or tumour interact with the parathyroid system; this: (1) increases the release of calcium from the bones, and (2) increases the absorption of calcium in the gastrointestinal and renal systems. Patients with hypercalcaemia present with a variety of symptoms including nausea and vomiting, osmotic diuresis, and central nervous system dysfunction.
Treatment for hypercalcaemia focuses on intravenous rehydration, and addressing symptoms using relevant medications. Intravenous bisphosphonates are also used to control hypercalcaemia, though these typically have a slow onset. However, hypercalcaemia often recurs, and eventual bisphosphonate resistance may occur. Hypercalcaemia is often a terminal event - care focuses on symptomatic management.
- Brain metastases: Patients present with a variety of signs and symptoms - including cerebral oedema and raised intracranial pressure, headache, seizures, nausea / vomiting, and confusion / agitation / psychosis. Treatment focuses on managing symptoms, and the use of anti-cancer therapies to reduce the size of the metastasis. Brain metastases carry a poor prognosis.
- Liver and lung metastases: liver and lung metastases are common. Again, treatment focuses on managing the symptoms, and use of anti-cancer therapies to reduce the size of the metastases.
- Superior vena cava obstruction: this often occurs due to a cancerous mass and / or grossly enlarged lymph nodes. Patients present with non-specific symptoms such as swelling of the face and arms, dyspnoea, hypoxia and cyanosis, and heart palpitations or arrhythmias. It is rarely life-threatening; management is usually symptom-focused. Chemotherapy and radiotherapy may also be used, and surgical stenting may be performed. Thrombolysis may also be indicated.
- Obstructive nephropathy: the ureters are obstructed by a cancerous mass, or by organs which have been displaced, causing renal failure. Patients present with a variety of non-specific signs and symptoms, including oliguria, confusion, hypertension, nausea / vomiting, oedema and myoclonic jerking. Treatment focuses on relieving the obstruction. Management of renal function is also important.
- Lymphoedema: an accumulation of fluid within the interstitial tissues. Lymphoedema is usually progressive, chronic and incurable. Patients often present with oedematous extremities and pitting oedema. Management focuses on supportive measures - for example, analgesia, skincare, exercise (within the patient's tolerance) to promote lymphatic drainage, and compression. Prevention of complications - such as cellulitis and lymphorrhoea - is a focus of lymphoedema management.
Advanced and / or metastatic cancer can produce a range of other significant complications - including haemorrhage, itch, fever and sweating.
Nurses working in palliative care must recognise that many palliative treatments can themselves have significant side-effects. These side-effects include:
- Gastrointestinal problems, such as oral mucositis, nausea / vomiting, diarrhoea and proctitis.
- Skin problems, including erythema and rashes, particularly with high-dose radiotherapy.
- Hair loss - which, although not life-threatening, can have psychological implications.
- Bone marrow suppression, resulting in complications such as thrombocytopaenia, neutropaenia and immunosuppression.
Standard nursing care is used to manage these symptoms.
Palliative care for communicable diseases
The most common communicable disease for which a person in the UK will receive palliative care is Human Immunodeficiency Virus (HIV), which progresses to Acquired Immunodeficiency Syndrome (AIDS). HIV/AIDS is rare in the UK. However, more than half of adults diagnosed with HIV/AIDS in the UK have a late-stage infection and are therefore candidates for early phases of palliative care. Additionally, more than a quarter of HIV-infected people in the UK are undiagnosed.
HIV/AIDS is a viral disease spread via contact with body fluid. In the UK, it is typically spread: (1) via sexual contact and (2) via injecting drug use. Once diagnosed, a person's life expectancy and their disease progression are variable, and depend on factors such as their tolerance of and adherence to antiretroviral (ARV) medication, and their development of resistance to ARV medications. For most people with HIV/AIDS in the UK, the infection can be considered a chronic, manageable disease - however, it is ultimately incurable and terminal; conversations about palliative care and advance care planning should begin early in the progression of the disease.
Management of HIV/AIDS in the palliative care setting
People living with HIV/AIDS face a number of significant comorbidities, are at risk of opportunistic infection, and may also experience psychosocial issues (e.g. stigma). There are a number of key principles associated with the provision of palliative care to people diagnosed with HIV/AIDS:
- Access to palliative care must not be restricted due to political / social issues.
- Active treatment should not be withheld at any stage of the disease, except if the patient makes an informed decision to do so.
- Palliative care discussions should take place at every stage of disease progress.
Palliative care usually involves the administration of ARV medication right up to the person's death, usually involving a combination of several drugs. Nurses should familiarise themselves with the types of ARV medications commonly prescribed where they work.
Use of ARV can rarely result in Immune Reconstitution Inflammatory Syndrome (IRIS). This occasionally occurs in people with advanced immunosuppression and opportunistic infection. ARV medication improves immune function, resulting in an overwhelming physiologic inflammatory response. Management involves treating symptoms and supporting the function of the immune system (e.g. through antibacterial and antiviral medications). Patients should be encouraged to view the occurrence of IRIS positively, as it indicates that ARV medications are working effectively.
In addition to the administration of ARV medication, palliative care involves the use of a variety of strategies to manage the other common physical symptoms of advanced HIV/AIDS infection. These symptoms include:
- Pain: a significant number of people with HIV/AIDS experience pain. This pain may originate from the nervous system (e.g. neuropathy), the gastrointestinal system (e.g. odynophagia, abdominal pain, anorectal pain, etc.) and / or the musculoskeletal system. Research suggests that pain in HIV is underestimated and under-medicated; this is an important consideration for nurses.
In patients with HIV/AIDS, pain management focuses on the use of medications and other therapies to correct the cause of the pain. Analgesia - often a complex combination of tricyclic agents, anticonvulsants and opioids - should also be used.
- Nausea and vomiting: a common symptom in patients with advanced HIV/AIDS. It is essential that the underlying cause/s are identified, and that strategies are implemented to manage them. Drug-induced nausea is common, particularly during initiation of ARV therapy or when medication regimens are changed. This may require alteration of ARV therapy and / or use of antiemetic medication. Nausea and vomiting may also be caused by gastric stasis, in which case a prokinetic is often prescribed. It may also be due to neurological problems, and appropriate medications are again prescribed.
- Diarrhoea: often due to opportunistic infections in the gastrointestinal system, or due to generalised inflammation of the bowel, pancreatic insufficiency, HIV/AIDS-related malignancy and / or intolerance to ARV medication. Underlying causes are addressed, as well as preventing and / or managing complications such as dehydration and weight loss.
- Oral problems: mouth ulcers, oral candidiasis and gingivitis are common. These can be very painful, and may impair consumption of food and fluids. Topical steroids, anti-septic mouthwash and antiviral / antifungal medications can be useful.
- Respiratory problems: pneumocystis pneumonia is one of the most common. Additionally, patients are prone to Tuberculosis, which may be multidrug-resistant and difficult to effectively treat. Most cases are treated aggressively with intravenous antibacterial medications; however, some patients may opt to avoid aggressive intervention.
- Ophthalmologic problems: People with HIV/AIDS are prone to ophthalmologic problems such as retinitis and keratitis. These conditions are often due to underlying infection; treatment focuses on addressing this infection.
- Dermatological problems: people with severe immunocompromisation are prone to dermatological problems, including yeast and fungal infections, psoriasis, viral infections, and scabies. These conditions are treated using standard nursing care.
- Malignancies: people with severe immunocompromisation are at increased risk of some types of cancer, including Kaposi's sarcoma and non-Hodgkin's lymphoma. These cancers are treated aggressively with anti-cancer therapies or conservatively, depending on the stage of disease progression and preferences for care.
- Neurological conditions: HIV-related neurological impairment, 'AIDS dementia', is a rare but serious complication of advanced infection. There is no treatment for this complication, and it often signals the terminal stage of a HIV/AIDS infection.
Privacy and confidentiality are particularly important considerations for patients with HIV/AIDS. There is significant stigma attached to HIV/AIDS, resulting partly from the perception that it is contracted through 'risky' sexual and drug use practices, and partly from the fact that HIV/AIDS is 'contagious'. A patient's requirements for privacy and confidentiality should be determined during the palliative care planning phase.
Stigma in relation to HIV/AIDS is an ongoing problem. Stigma may make a patient reluctant to seek testing or treatment, and may cause treatment non-compliance. Nurses must care for patients in a non-judgemental way and non-discriminative way.
Access to NHS funded services also varies. A significant proportion of people living with HIV/AIDS in the UK do not have UK citizenship - and therefore may be ineligible for NHS-funded services. Nurses must ensure they are familiar with policies and procedures, and patient alternatives, where they work.
Nurses working in palliative care settings should be both competent and confident in caring for patients with a variety of different types of cancer and communicable diseases, particularly HIV/AIDS. This chapter has provided a detailed overview of the symptoms and complications associated with cancer and HIV/AIDS, and their effective management in the palliative care setting.
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