- Hina Mirza
The purpose of this writing is to highlight issues of the patient in palliative consideration, which a patient faced throughout the disease process and at terminal stage of illness. Moreover, it will drag one’s attention towards some strategies to deal patient with advance cancer. A 54 year old female with known case of ductal cell carcinoma of left breast, came to the hospital with the complaint of oozing and pain in fungating wound large in size present at the primary site of tumor. When I encountered the patient, she was very drowsy and unable to talk due to mouth ulcers that have been developed a week ago. Upon taking history from the patient’s attendants, they verbalize that the patient got breast cancer for 1.5 years and since then she was on homeopathic treatment. Moreover, the patient initially didn’t inform anyone about her disease, not even to her husband. Later, when symptoms got exacerbate she disclosed her problem to the family members. Consequently, she was taken to a cancer hospital, where a doctor recommended her for a biopsy. Thus, the results revealed breast carcinoma. Even after, she didn’t consult to the doctor and continued her homeopathic medication. While taking care of the patient, I got an opportunity to approach her about the reasons behind postponement in the diagnosis and the variables that make her condition decline. One of the reasons she gave in regards to not counseling a specialist or not having a legitimate treatment was monetary instability, an alternate reason was absence of awareness with respect to tumor treatment and misconceptions identified with its side effects. Besides, after a time of 1 year when her condition got crumble and a tumor in her breast uncovered as fungating wound, a relative took her again to the cancer hospital, from that point she was referred to the Baitul Sukoon for palliative consideration. The patient verbalizes torment because of mouth ulcers and as indicated by specialists her tumor has been metastasized to different parts of the body including liver and brain. Moreover, the patient likewise expressed that she will give priority to the treatment other than surgery on the grounds that she is afraid about losing her breast and it will alter her body image. In addition to it, the patient’s attendant stated that her nutrition pattern has been also effected which causes weakness. The patient was prepared and very much aware of her condition. For a week she has been on laxatives and as indicated by the specialist she had developed encephalopathy. Following 2 weeks of hospitalization; she died because of deteriorated condition.
Breast cancer is a serious health issue among women throughout the world. According to a consultant at Shaukat Khanam Memorial Cancer Hospital, in Pakistan it is estimated that 1 in 9 women develops breast cancer once at any stage of their life. Cancer affects a person not only physically, but also cause spiritual, sexual, and psychological distress. When considering a physical domain of the patient in palliative care, she was suffering from pain and mouth ulcers which as a result altered her communication pattern. On the other hand, she was very drowsy, her dietary intake has also decreased and the patient has not passed stools for 2 days. Looking forward to the above mentioned symptoms firstly, mouth sore is among common indications in cancer patient in light of the fact that when patients are in critical condition, they lack oral hygiene as a result becomes more prone to infection. In addition to it, infections in cancer patients remain a major complication due to effects of malignancy i.e. neutropenia. These patients require prompt antibiotics (Bodey, 2004). As the patient mentioned in the above scenario was getting augmentation. As indicated by literature, oral cavity plays a vital role in communication and dietary pattern and in cancer patient alterations in the oral cavity is common because of the certainty of diminished in preventive consideration (Eilers & Million, 2011). Secondly, impaired oral cavity results in decreased intake of food that is critical at this stage of cancer. Decline in nutrition is considered normal at the terminal stage of life as a result malnutrition, cachexia is commonly found in patient with palliative care (Capra, ferguson, & Ried, 2001). Thirdly, the patient was showing symptoms of encephalopathy. As literature evidenced that as an outcome of some metabolic disturbance, encephalopathy is a common clinical syndrome in cancer patients (Lore, Anne, Patrick, & Simon, 2012). Relating it to the above scenario, the patient has been bed ridden for 2 months, not passing stool and she has been on laxative since 2 weeks. The purpose of giving laxative was to prevent hyper ammonia in the body which can cause encephalopathy. According to Willson, Nott, Broadbridge, & Price (2013) hepatic encephalopathy as a result of liver infiltration is common among metastatic malignancy.
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Analyzing the psycho-social factors that becomes hindrance to care and approach to treatment as part palliative care were fear related to losing her breast, unawareness of the patient and her family members about disease and treatment options linked with socio-cultural barriers, financial issues, and preference towards alternative drugs i.e. homeopathic treatment. According to a research it was found that patients with breast cancer who consulted a doctor had fear of mastectomies. Firstly, the reason behind fear was lack of awareness about treatment option available for breast cancer such as procedures that are less invasive like lumpectomies. Due to the fact, women avoid availing proper check up and maintained non-compliance to the cancer therapy (Memon et al., 2013). Secondly, among socio-cultural barriers, lack of information related to disease due to low education reported by women. This ultimately delays the approach to health care, even with prominent signs and symptoms of a disease such as nodule, edema and erythema. One of the reasons behind avoidance is social myths, society including friends and family gives different meaning to these symptoms, which minimize its seriousness. Moreover, cultural barriers have strong impact on getting awareness related to breast cancer. According to Banning, Hassan, Faisal, & Hafeez (2010) many Asian women do not perform self breast examination because of a taboo related to touching own body parts, feeling embarrassment to discuss intimate body parts and to consult a male physician. According to literature myths around the pathology of breast cancer causes late diagnosis and hindrance to care (Goncalves et al., 2014). Thirdly, cancer treatment is considered financially devastating burden to the family because they have to pay for the treatment by themselves (Daher, 2012). Therefore, initiating treatment becomes psychologically distressing for the patient and for the family. Relating it to the scenario, the patient didn’t disclose her problem to the family member due to myths and unawareness related to disease. Lastly, in my opinion the main factor that contributes to delay in diagnosis and worse the patient’s condition was preferences for homeopathic medicine and this again could be linked with lack of awareness related to the availability of treatment options. According to a research it’s commonly reported that individual with cancer seek alternative medicine due to misconception associated with treatment options (Daher, 2012). Moreover, unconventional methods, including traditional herbal medicine and healers over doctors for cancer treatment also reported in a study of women associated with delay seeking medical advice (Memon et al., 2013).
Numerous factors contribute towards, delay and obstruction in treatment of breast malignancy. In terms of prioritize the variables that add to delay in diagnosis were unawareness related to the options available for treatment, socio-cultural hindrances, choosing alternative medicine, and financial issues. On individual level health professionals must respect autonomy of the patient and inclination of treatment. It is one’s obligation to explain potential harm of such alternative treatment. Besides, when health care prrovider experience patients with breast tumor, they should explain its risk factors and preventive measures to the patient and their family members for precautionary purpose. On hospital level, staff should be well trained to deal cross culturally and care for the patient with interdisciplinary aspects and according to patients’ needs. These can include care according to patient’s comfortability level, counseling patient’s family regarding disease and helping them to select suitable and appropriate treatment options. Moreover, the Government should organize an awareness program to educate the patient with respect to primary prevention, which includes awareness related to self breast examination, treatment options that are less invasive as a secondary prevention and tertiary prevention that should include the concept of palliative care, and information about the institution that provide palliative and hospice care. On the other hand, female health care professionals should be given first priority to be trained to deal with culturally sensitive issues. Together, these contributions can help to eradicate issues related to breast cancer and will support patients suffering from it.
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