This assignment will critically explore one impact of cancer treatment, examining the physiological nature of the impact. I will analyse strategies for alleviating the impact, considering the contribution of the multi-disciplinary team. I will discuss the contribution of healthcare professionals to holistic care analysing the professional and ethical dimensions of practice. Finally I will evaluate the effectiveness of the current management of the identified impact.
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The one impact of cancer treatment which I have chosen to look at is chemotherapy induced diarrhoea (CID). The London Cancer Alliance (2013) reports that patients receiving chemotherapy are at risk of developing severe diarrhoea, and the prevalence has been reported to be as high as 50–80%. Sherman (2008) explains that diarrhoea has a significant impact on quality of life and can contribute to malnutrition, weight loss, immunosuppression, and mortality. I have personally encountered CID in my practice and have seen how debilitating it can be for service users both physiologically and psychologically.
According to Stein (2010) the pathophysiology of chemotherapy induced diarrhoea is multifaceted, complex and still undergoing further investigation.
This is also acknowledged by Gibson and Keefe (2006) who believe that CID is likely to be caused by combinations of varying factors which include, altered gut motility; colonic crypt damage, impairing water absorption in the colon, changes to intestinal microflora, affecting absorption and altered fluid transport in the colon.
Robinson and Dobish (2007) believe that the absorptive and secretory capacity within the gut is altered during chemotherapy due to the toxicity damaging the intestinal epithelium, inflammation of the bowel wall and superficial necrosis. Which according to Stringer (2009) causes a difference between secretion and absorption in the small bowel resulting in diarrhoea.
Viele (2003) suggests that there are two mechanisms by which chemotherapy may induce this. First, the diarrhoea is caused by changes in intestinal absorption which may or may not be accompanied by excessive electrolyte and fluid secretion. Second, the diarrhoea may be a consequence of a combination of mechanical and biochemical changes caused by the chemotherapy.
These intestinal functional changes are thought to be a result of direct toxicity of the chemotherapy on the colonic crypt stem cells. Death of these cells leads to a cascading effect where immature crypt cells attempt to compensate by releasing more secretory compounds (Viele, 2003).
The small intestine is also thought to play a role whereby the villi are unable to absorb fluids correctly, leading to a skewed ratio of fluid absorption and secretion. In addition, chemotherapy is reported to destroy the brush border enzymes, which are responsible for the digestion of both carbohydrates and proteins, and this causes more gut-wall secretions to occur (Rutledge and Engelking, 2008).
Sharma (2005) informs us that if CID is uncontrolled the consequences can be devastating both physically and psychologically. According to Cherny (2008) diarrhoea can lead to, dehydration, electrolyte imbalance, renal issues and even death. Viele (2003) reminds us that the impact if CID is not just physiological, the psychological effects of diarrhoea include depression, social isolation and anxiety. Patients suffering from CID will often require additional healthcare resources, such as admission, which will raise the cost of the patients care for the healthcare service (Dranitsaris et al 2005). Arnold (2005) explains that CID can interfere with cancer treatments affecting scheduled treatment plans, dose reductions ultimately leading to a worse outcome.
In a reflective study of cancer patients who acquired CID, Arnold et al (2005) discovered that 65% of patients experienced a decrease in dose intensity, a dose reduction was required in 45%, a delay in treatment was experienced in 71%, and 3% had their therapy discontinued. Maroun et al (2007) conclude that treatment delays, discontinuation and dose reductions have a direct adverse effect on patient mortality and morbidity. Therefore clear objectives must be in place in order to manage chemotherapy induced diarrhoea effectively. According to Skelley (2005), healthcare professionals must promptly diagnose and treat patients with CID, minimise treatment delays, maximise chemo intensity and therefore maximise the patients’ quality of life whilst undertaking treatment.
Skelley (2005) states that to manage diarrhoea in an acute setting effectively healthcare staff need to maintain an accurate stool chart and should grade diarrhoea using the National Cancer Institute Common Toxicity Criteria for Diarrhoea. The London Cancer Alliance (2013) supports the use of a grading system and shows one in their management literature and has added symptoms into the table to help aid in grading diarrhoea more effectively.
The LCA (2013) add that mucositis and neutropenia from the chemotherapy treatment can also significantly increase complications associated with CID. Prompt recognition and swift appropriate treatment are essential. Therefore by completing the aforementioned measures, medical staff are enabled to choose the correct treatment options and it also helps to monitor the effectiveness of the treatment. Also we must ensure that a stool culture taken, so as to rule out any infections or other causes which could further prolong or alter treatment plans.
It is important for healthcare professionals to actively encourage patients to report their bowel movements, because patients can fear that reporting diarrhoea will delay their treatment (Maroun, 2007). As a healthcare professional we should aim to reassure patients that prompt diagnosis and early treatment can prevent delays to their chemotherapy.
According to Cherny (2008) patients with CID should have a full assessment including medical history, dietary history and medication review. Before treating CID other common causes of diarrhoea should be considered and excluded. These could include, adverse medication effects, concurrent Disease such as, Crohn’s disease, diverticulitis and ulcerative colitis, viral Infection, bacterial Infection, faecal Impaction, diet and psychological Factors (LSA, 2013).
Benson (2004) believes that patient education is the vital underpinning to the management of CID and before commencing chemotherapy, patients must be fully informed of the potential risks and what actions to take, if they develop diarrhoea.
Patients will require nutritional advice and the LCA (2013) guides us by showing the initial management for CID which we can in turn offer to patients. This includes drinking 8–10 large glasses of clear fluids per day to prevent dehydration and stopping lactose-containing products since lactose intolerance can develop when the mucosa is damaged. Patients need to avoid spices, high-fibre foods, high-fat foods, caffeine, alcohol and fruit juices. Small frequent meals such as bananas, toast and plain pasta are also recommended. There are many more aspects to dietary advice therefore input from a dietician would be beneficial.
Benson et al (2004) show that in diarrhoea grades 1–2 Loperamide is the recommended medication, 4mg followed by 2mg after every loose stool up to 16mg daily. If diarrhoea persists, high dose Loperamide should be used and Codeine Phosphate 30–60mg QDS can be added, also a stool culture needs to be taken if not previously done. The patient will need to be admitted to hospital if not already an inpatient if the diarrhoea persists or becomes grade 3-4 after 24-48 hours. At this point Octreotide is the recommended treatment as a sub-cutaneous injection, 300mcg/24hr for 5 days, increasing to 600mcg/24hr if not effective (LCA, 2013).
According to Barbounis et al (2001) Octreotide has a 60% – 90% success rate in resolving persistent diarrhoea. Zidane (2001) explains that although Octreotide has proven to be more successful than Loperamide, it still remains as a second line treatment due to its high cost.
Chemotherapy induced diarrhoea has tremendous effects on patients’ quality of life, the management of cancer patients requires increased attention to this side effect from nurses. Targeted education is needed to help nurses implement systematic assessment and documentation.
Nurses must ensure to communicate effectively with patients and caregivers in every setting about the nature of diarrhoea and its causes, as well as develop appropriate interventions for each individual. As such, nurses need to maintain current knowledge of the causes and available treatment strategies for CID. It is also imperative to remember the beneficial effect that diet may play in alleviating diarrhoea symptoms.
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